BIA-ALCL January 2018 Breast Implant Associated Lymphoma Update

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.

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 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.

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.

Risk Factors

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

  1. T – Textured Breast Implants – There have been no reported smooth-walled device cases at this time.
  2. 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.
  3. M – Mutations – There may be a link with genetic mutations in JAK1 and STAT3. Further research is necessary.
  4. 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.

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Blepharoplasty Video (Eyelid Lifts)

Posted January 06, 2018 in Eyelid Lift (Blepharoplasty), Home, Videos

Saggy upper eyelids and lower eyelid bags make us look tired and add years to our face. This is why the Eyelid Lift remains one of the most popular cosmetic plastic surgery procedures which I, and other Board Certified Plastic Surgeons, perform.

Eyelid lifts can literally open our eyes, making us look more awake and alert. As the upper eyelid skin becomes more redundant, it begins to rub off upper eyelid makeup and can come to rest on the eyelashes. The result is a heavy sensation and a worn down appearance, even when we are well rested.

Eyelid lifts can literally open our eyes, making us look more awake and alert. As the upper eyelid skin becomes more redundant, it begins to rub off upper eyelid makeup and can come to rest on the eyelashes. The result is a heavy sensation and a worn down appearance, even when we are well rested.

Blepharoplasty means eyelid changing, and it can rejuvenate our appearance and recharge our persona. San Francisco Bay Are Board Certified Plastic Surgeon, Dr. Joseph A. Mele, discusses eyelid rejuvenation and narrates numerous blepharoplasty before and after pictures on this video segment taken from KRON 4’s Body Beautiful.

Blepharoplasty Video (Eyelid Lift)

The following video segment reviews Eyelid Lifts and illustrates what Blepharoplasty can do with numerous Eyelid Lift Before and After Pictures.

The preview screen on the above Blepharoplasty Video shows how excess upper eyelid skin can weigh down the upper eyelid. In the picture on the left, the upper and lateral visual fields are obstructed and the skin is resting on the eyelashes, making the normal use of eye makeup impossible. In the after picture on the right, the eye and the upper eyelid are now visible.

The Correction of Lateral Hooding

In these Blepharoplasty Before and After Pictures, the before picture on the left shows the lateral brow skin completely covering the outer eyelid. In the after picture on the right, the brow skin is elevated, giving a much cleaner, refreshed and younger look.

In these Blepharoplasty Before and After Pictures, the before picture on the left shows the lateral brow skin completely covering the outer eyelid. In the after picture on the right the brow skin is elevated, giving a much cleaner, refreshed and younger look.

Lateral Hooding occurs when the eyelid or brow skin descends past the outside of the eye opening also known as the lateral orbital rim. Skin in this position blocks the lateral gaze, like blinders do on a horse. It also impacts a sleepy and older look to our eyes. In the above example, simply removing the excess skin corrected the problem. When the brow itself sags, a Brow Lift may be recommended.

Correcting Upper Eyelid Hooding

In the upper (before) shows severe hooding of the entire upper eyelid. After her blepharoplasty, her upper eyelids are now visible, and a smooth upper eyelid crease has been created.

The upper (before) photo shows severe hooding of the entire upper eyelid. After her blepharoplasty, her upper eyelids are now visible, and a smooth upper eyelid crease has been created.

Sometimes the upper eyelid skin is so excessive that the entire upper lid is hooded. Wearing upper eyelid makeup properly is short lived at best. By removing the excess skin, the upper eyelid and lashes are revealed, and a natural eyelid crease is created.

Blepharoplasty Consultations

If you would like to schedule a personalized consultation appointment, give me a call at (925) 943-6353. There is no substitute for an in-person eyelid consultation with an experienced and qualified, Board Certified Plastic Surgeon. A brief exam and medical history are needed to be sure the procedure is right for you. Safety and predictability are the most important aspects of any surgery, but this is especially true of elective plastic surgery.

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Liposuction Video SF Bay Area Liposculpture

Posted December 30, 2017 in Daddy Makeover, Home, Liposuction, Mini Tummy Tuck (Mini Abdominoplasty), Tummy Tuck (Abdominoplasty), Videos

Liposuction is great for removing disproportionate, localized areas of fat accumulation. On today’s video I discuss Liposculpture and share numerous Liposuction before and after pictures from my latest segment from KRON 4’s Body Beautiful.

What Are The Best Areas For Liposuction?

Liposuction removes disproportionate fat. In the above before and after pictures, Liposculpture is used to further enhance a Tummy Tuck.

Liposuction removes disproportionate fat. In the above before and after pictures, Liposculpture is used to further enhance a Tummy Tuck.

As a San Francisco Bay Area Board Certified Plastic Surgeon, I perform Liposuction on many areas of the body. The best areas are localized accumulations of fat which stick out from the surrounding areas. The convexities can be contoured with Liposculpture to bring them back into proportion and enhance your appearance. Sometimes the fat can be repurposed like with the Brazilian Buttocks Lift.

Liposuction Video

The following video segment reviews Liposuction and reveals the secrets of Liposculpture with numerous Before and After Pictures.

The video’s preview screen above shows the results of Liposuction alone. Fine Liposuction cannulas were used to contour the belly, flanks, back and thighs, and enhance this patient’s feminine curves.

Liposuction Frequently Asked Questions

Love handles handled with Liposuction. By carefully sculpting the lower back fat, Liposculpture reduces the muffin top. Unsightly bulges are transformed into more attractive curves.

Love handles handled with Liposuction. By carefully sculpting the lower back fat, Liposculpture reduces the muffin top. Unsightly bulges are transformed into more attractive curves.

Many of the frequently asked questions about Liposuction are reviewed in the Liposuction Video above. If you have more questions, be certain to select Liposuction in the sidebar under Search By Category. More information is also available on my main website’s Liposuction Page.

Personalized Answers to Your Questions

I use Liposuction almost every week to treat gynecomastia. The combination of Liposculpture to remove excess chest fat and the direct excision of the firm, stubborn glandular tissue can reduce and masculinize a man's chest.

I use Liposuction almost every week to reduce gynecomastia. The combination of Liposculpture of excess chest fat and the direct excision of the firm, stubborn glandular tissue can flatten and masculinize a man’s chest.

There is a lot of Liposuction information available on the San Francisco Plastic Surgery Blog. It’s a good start; however, the only way to get specific answers to your Liposuction Questions is during an in-person consultation with an experienced qualified professional. Call (925) 943-6353 today, to schedule an appointment at our San Francisco Bay Area Plastic Surgery Clinic in Walnut Creek, CA.

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Mommy Makeover Before and After Video – SF Bay Area

Posted December 23, 2017 in Breast Augmentation, Breast Augmentation Lift, Breast Lift (Mastopexy), Home, Mommy Makeover, Tummy Tuck (Abdominoplasty), Videos

The combination of Breast and Belly Enhancement has been coined the Mommy Makeover. Since the breasts and belly often change after childbirth, the combination is most often performed for mommies. Children, however, are not a prerequisite as any weight gain and loss can cause similar changes.

Mommy Makeovers After Weight Loss

Mommy Makeovers can be performed after weight loss, too.

Mommy Makeovers can be performed after weight loss, too.

The combination of breast and belly rejuvenation is frequently requested after bariatric surgery or larger weight loss after diet and exercise. As with pregnancy, both areas stretch with weight gain, and then deflate and often sag after the weight is lost, taking the shine off all the hard work. The Mommy Makeover procedure can enhance the breast and the belly in a single operation. The Mommy Makeover Video below shows additional examples.

Mommy Makeover Video (Breast and Belly Enhancement)

This Mommy Makeover video narrates several Mommy Makeover Before and After Pictures and provides additional information on the Mommy Makeover procedure including options and recovery.

Mommy Makeover Results Last

This mommy has been shown here before. She is maintaining her healthy lifestyle and her beautiful results.

This mommy has been shown here before. She is maintaining her healthy lifestyle and her beautiful results.

You can expect your Mommy Makeover to last. With proper maintenance, the procedure is very effective at improving body contours long term. If you are planning to have children, it is recommended to have them before the Mommy Makeover.

Mommy Makeover With A Brazilian Butt Lift

The Mommy Makeover can also be combined with the Brazilian Buttocks Lift.

The Mommy Makeover can also be combined with the Brazilian Buttocks Lift.

For selected patients, the Mommy Makeover can be combined with fat grafting to the buttocks, aka the Brazilian Buttocks Lift. The upside is added shape to the buttocks by grafting fat from the belly and back that would usually be discarded during the tummy tuck. The downside is trying to avoid sitting/laying on the fat grafts while recovering. Sometimes separating the procedures is recommended.

Mommy Makeover Consultations

To schedule your personal Mommy Makeover Consultation, tailored to your specific needs, call (925) 943-6353. As a Board Certified Plastic Surgeon, I offer a wide range of options for both breast enhancement and tummy tightening. Check out the San Francisco Plastic Surgery Blog and my main websites for more information. If you have a question, just ask via the contact forms available on this and all our webpages.

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Breast Augmentation With Breast Implants Bay Area

Posted December 16, 2017 in Breast Augmentation, Home, Mommy Makeover, Videos

Breast Implants can enlarge and enhance the shape of a woman's breasts.

Breast Implants can enlarge and enhance the shape of a woman’s breasts.

Breast Augmentation remains one of the most requested Cosmetic Plastic Surgery procedures year after year. My San Francisco Bay Area Breast Augmentation patients are no exception. Whether breast shape or volume has become a problem postpartum, after weight loss or if you have always had small breast, Breast Implants may be the answer you are looking for.

Breast Augmentation Before and After Pictures

Breast Implants can put the stuffing back into deflated breasts.

Breast Implants can put the stuffing back into deflated breasts.

This week I discussed Breast Augmentation on the SF Bay Area’s New Station, KRON 4, with host Janelle Marie. The video segment below includes information about Breast Implants and how they are used. In it, I narrate multiple Breast Implant Before and After Pictures of my actual patients.

Breast Augmentation Video (Breast Implants)

Breast Augmentation Explained

Breast Augmentation with Breast Implants has been around for over 50 years. The procedure involves creating a pocket for the Breast Implant behind your breast tissue to augment the breasts. This enhances both the size and shape of the breasts. More information is available here on the San Francisco Plastic Surgery Blog, by selecting “Breast Augmentation” under the “Search By Category” heading in the sidebar. There is also information about Breast Augmentation Lifts, Breast Implant Selection, Breast Implant Revision, Breast Implant Removal and a wide variety of other cosmetic breast, face and body procedures.

The best breast augmentation is achieved by selecting breast implants that are proportionate to the chest.

The best breast augmentation is achieved by selecting breast implants that are proportionate to the chest.

Breast Augmentation Consultations

If you are considering Breast Enhancement Surgery, call (925) 943-6353, today, and schedule a personal consultation appointment, tailored to your goals. We are conveniently located in the East San Francisco Bay Area city of Walnut Creek, CA.

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Cup sizes and CCs – SF Bay Breast Augmentation

Posted November 19, 2017 in Breast Augmentation, Home

How many ccs in a c-cup? This is a question I hear every day. The question is simple; however, the answer is complicated. I will try to explain in today’s San Francisco Plastic Surgery Blog post.

In 1937, Warner introduced its Alphabet Bra with four cup sizes (A, B, C and D)

In 1937, Warner introduced its Alphabet Bra with four cup sizes (A, B, C and D)

Math is Beautiful

Volume of a hemisphere

Please explain how this equation answers the question,”How many ccs are there in a C-cup?”

If you are still reading this, I will explain. The equation above is the approximate volume of a breast, given its radius (r). The volume of the breast is directly related to its radius cubed. In other words, if you double the radius of the breast, this will increase the volume eight-fold.

The upside to using an equation is that equations are 100% objective. Measuring the base width of the breast gives us the radius, and via the equation the volume. The beauty of mathematics is that there is a defined answer. The downside is that even this simplified equation is hard to relate to for most people. Additionally, the actual volume will be less than calculated, because breasts are not perfect hemispheres. At least they should not be, but this segues nicely in the subjective side of the C-cup.

Objective vs. Subjective

At the latest American Society for Aesthetic Plastic Surgeon (ASAPS) meeting, a company was offering a high-tech laser scanner that can be used to measure the exact contours of a patient’s body. If plastic surgery were 100% objective, this would be great; however, even though we can measure and calculate volumes with great precision, what exactly a C-cup represents is subjective. It depends on each patients experience, body shape and even the brand of the bra worn.

Bras were much pointier in the past.

Bras were much pointier in the past.

It is estimated that 75-80% of women wear the “wrong” bra size. My grandmother was a corsetiere. She sold lingerie at I. Magnin’s in Walnut Creek until the day it closed. She fitted women for bras, and even for prosthetics after a mastectomy. She had a loyal following, because she could find the right size for each customer and each manufacturer, and she confirmed that most women wear the wrong bra size. On the other hand, we wear what is comfortable.

Why Women Wear the Wrong Size Bra

Bra researchers have studied what size bras women wear and have documented through the years that most women do not wear the size bra for which they measure. Moreover, two trends are consistent. Women with smaller breast tend to wear bras which are too large, and women with larger breast tend to wear bras which are too small. Oprah Winfrey had an entire show dedicated to this, so it must be true. I think it’s an extension of the saying, “The grass is always greener on the other side of the hill.” In this case, the hill is a C-cup.

Inflatable cup sizes.

Inflatable cup sizes.

To add to the confusion, boutiques that tailor their products to younger/thinner women tend to inflate the cup size for a given volume. The best example is Victoria’s Secret. It is no secret that if you wear a C-cup in VS, you likely wear a B-cup in other mainstream bra manufacturers like Warner’s and Bali. This brand specific sizing, and often style specific sizing, leads to further confusion over what a C-cup really represents. There is no industry standard for bra sizing, so if you wear a 34C from company A, a 34C from company B may not fit.

Cup Volumes And Band Size

Cup volumes are also dependent in band size. The measurement under the breasts, the size of the chest without including the breasts, determines the band size. A larger chest means a larger band size. In the US, the measurement is made in inches, and then 4 or 5 is added to this to get to an even number. Other countries simply use the closest even number, so it is important to know the method of sizing.

Measurements are made around and below the bust for bra fittings.

Measurements are made around and below the bust for bra fittings.

When measuring around the breasts, each increase of one inch equals and increase in one cup size. Again, there are variations, some countries use 2 cm and others may use 3 cm. Since is takes more volume to increase an inch around a larger chest, cup volumes increase, for a given letter size, as the band size increases. For example, the cup volume of a 34C is 25% larger than that for a 32C and 23% smaller than that for a 36C.

So How Many CCs Are There In A C-Cup?

Bra sizing can be frustrating and confusing, and this is why it is hard to promise a certain cup size after Breast Augmentation. As it was so eloquently put by a presenter at the ASAPS annual meeting, “If a patient wants a guarantee for a specific cup size, I tell her I can, if I get to buy the bra.”

The simple answer: Objectively: When we do the math using the most commonly used US system of bra measurement, a 34C cup is 480ccs.

The real answer: Subjectively: It depends. It depends on many factors including:

  • Who’s C-cup you wear. A pretty, cleavage enhancing, Victoria’s Secret bra may only hold half the volume calculated above. Some of the cup size is filled with padding, and the wire length may be reduced to force the breasts together.
  • How you like your bra to fit. You can wear a cup size larger if you are smaller, or wear a tighter band size to support larger breasts. Research shows most women do.
  • Skin tightness. Tighter, higher breasts fit into a bra differently than deflated, lower breasts. Larger natural breasts do not fill the upper portion of the cup without support, while larger implants do.

How To Choose The Best CCs For Your Breast Augmentation?

This is a question that is asked every five minutes on the Internet, if not more frequently. The best way is to:

  • Seek guidance from a Board Certified Plastic Surgeon who is experienced and fully trained in Breast Augmentation.
  • Be honest with yourself, your goals and your surgeon.
  • Do your homework. Buy a bra that is the size you want, the band number should be the same, and stuff it. Ziplock bags filled with (uncooked) rice is a simple way to vary the size and try on different looks. Be sure to use different clothes too, to see how your look changes. This short post is as true today as the day it was published: How to Choose the Correct Breast Implants: Size.

Also remember, there is no perfect answer. Your ideal size may change from day-to-day, and through the years. So the goal should be to find your comfort zone and aim for the center of it. Additionally, breasts change. They can change with normal monthly cycles. Breast size and shape morph as we age, have children and gain/lose weight.

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Fire and Plastic Surgery

Posted October 22, 2017 in Home, Patient Safety

Fires have devastated wildlife and neighborhoods alike in the San Francisco North Bay Area.

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.

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.

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.

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Otoplasty SF Bay Area (Ear Pinning)

Posted October 09, 2017 in Ear Shaping (Otoplasty), Home, Videos

Prominent ears can be a source of embarrassment and teasing. Cosmetic Ear Surgery (Otoplasty) includes Ear Pinning to reduce the appearance of prominent ears. Many of my patients are adults who have thought about having the procedure for some time. One of the most common reactions I hear after surgery is, “I wish I had done this sooner.” Otoplasty is a one or two hour procedure that can be performed as an outpatient, and for the right patient, it can make a huge difference.

Otoplasty For Adults

These otoplasty before and after pictures show how prominent ears can be reduced. The entire ear is pinned back. In this case, the upper ear is brought in more than the lower aspect to balance the projection.

These otoplasty before and after pictures show how prominent ears can be reduced. The entire ear is pinned back. In this case, the upper ear is brought in more than the lower aspect to balance the projection.

The gentleman above waited years before having Cosmetic Ear Surgery. He had prominent ears, which are typically more prominent at the top. He also had asymmetry of his ears with differences in shape, prominence and rotation. Each area was addresses and improved with his Otoplasty, making him one happy patient.

Ear Pinning Video

This video segment is from the San Francisco Bay Area’s News Station, KRON 4’s, Body Beautiful with Dr. Joseph Mele. The Otoplasty Video reviews the techniques, recovery and procedure of Otoplasty, and illustrates the results with Otoplasty Before and After Pictures.

Otoplasty Video (Ear Reduction)

Otoplasty For Children

There are two peaks in the age of Otoplasty patients. Young adults are the most common, but a significant number of children undergo Otoplasty also. It is one of the most common cosmetic plastic surgery procedures performed for children in my Walnut Creek Plastic Surgery Clinic, and in general. It is important to wait until at least age 5, for the ear to grow to near its adult size before proceeding.

Prominent ears are something we are born with. Ear pinning or Otoplasty is deferred until age 5, because at 5 -years-old, the ear is 85% of the adult size.

Prominent ears are something we are born with. Ear pinning, or Otoplasty, is deferred until age 5, because at 5 -years-old, the ear is 85% of the adult size.

The patient above has the advantage of long hair to cover her ears; however, her ears gave her trouble when she wanted to wear her hair up. This is a common problem for young athletes in particular. After her ear pinning, she could return to playing sports with confidence.

Otoplasty Recovery

Once healed, the ear does not require any special treatment, and recovery from surgery is just a few weeks. A head dressing is worn for the first week, and then a sweatband is worn at night for a few months, to keep the ears from folding forward while sleeping. Once the initial dressing is removed, no dressing is needed while awake.

Cosmetic Ear Pinning Consultations


If you are considering Otoplasty
for yourself or your child, be certain to consult with a Board Certified Plastic Surgeon in your area for detailed and specific advice. In the greater San Francisco Bay Area, call (925) 943-6353 and schedule a private consultation appointment, tailored to your needs.

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Gynecomastia Reduction SF Bay Area (Male Breast Reduction)

Posted October 02, 2017 in Breast Reduction, Breast Reduction (Men), Home, Liposuction, Videos

Disproportionate development of male breast tissue is called Gynecomastia. It’s also called man boobs, or moobs for short, and Gynecomastia Reduction is a cosmetic plastic surgery procedure which I perform every week.

Gynecomastia Reduction Surgery

The above Gynecomastia reduction surgery before and after photos show what is possible with a combination of liposuction and direct excision for an enlarged male chest.

The above Gynecomastia reduction surgery before and after photos show what is possible with a combination of liposuction and direct excision for a enlarged male breasts.

Asymmetry is more the rule than the exception for Gynecomastia. For the Gynecomastia Reduction patient shown above, the right breast was significantly larger than the left, both areolae where dilated and the breasts appear feminized. In fact, the feminine appearance of the breasts is what gives rise to the term Gynecomastia (feminine breasts).

Gynecomastia Correction was accomplished with a combination of liposuction to debulk the disproportionate fat and direct excision of the glandular tissue located under the nipple. The end result is a masculine chest that conforms to the pectoralis major muscles, a reduction in the size of the areolae and significant improvement in his asymmetry, all with minimal scarring. A short incision is hidden in each axilla (armpit) and around the lower border of the areolae (from 4 to 8 o’clock).

Gynecomastia Reduction Video (Male Breast Reduction)

Puffy Nipples

The start screen for the above Male Breast Reduction Video shows a man with Puffy Nipples. The enlarged and protuberant areolae are due to overdevelopment of the glandular breast tissue located directly behind the nipple. A focused surgical approach was used in this cases to remove the excess tissue and allow the nipple-areolar complex (NAC) to conform with the chest and look masculine.

The above Gynecomastia Reduction Video is from the San Francisco Bay Area’s News Station, KRON 4‘s, Body Beautiful. This segment discussed Gynecomastia Treatment and shows numerous examples of Gynecomastia Before and After Pictures to illustrate what the procedure can do for the properly selected patient, in the hands of an experienced, Board Certified Plastic Surgeon.

Global Gynecomastia

When Gynecomastia is distributed throughout the chest, more must be done. In this case, Liposuction was used to remove the bulk of the disproportionate chest tissue. If a glandular component is present beneath the nipple, this tissue also needs to be removed.

When Gynecomastia is distributed throughout the chest, more must be done. In this case Liposuction was used to remove the bulk of the disproportionate chest tissue. When a glandular component is present beneath the nipple, it is unlikely that liposuction alone will remove it, and this tissue is removed directly.

For more globally distributed Gynecomastia, Liposuction is used. Liposuction has the advantage of a long reach through a small incision. Often the 1/4 – 3/8 inch incision is hidden up in the axilla (armpit). For Pseudogynecomastia, breast enlargement due to fat and not glandular development, Liposuction alone is often enough to contour the chest. When a glandular component is also present, direct excision is also used to avoid creating a puffy nipple.

Gynecomastia Reduction Consultations

Every Gynecomastia Reduction Surgeon should be versed in multiple techniques of Gynecomastia Reduction. Depending on your situation, liposuction, direct excision of the gland, skin reduction or a combination of these may be recommended.

To find out what your options are, call (925) 943-6353 today and schedule a private, personalized consultation in our Walnut Creek Plastic Surgery office. If Gynecomastia is bothering you, learn what treatments are available from an experienced, Board Certified Plastic Surgeon.

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Breast Implant Revision SF Bay Area

Posted September 25, 2017 in Breast Asymmetry, Breast Augmentation, Breast Augmentation Lift, Breast Implant Revision Surgery, Home, Videos

Breast Augmentation with Breast Implants remains the most popular cosmetic plastic surgery. Three to four-hundred-thousand women have Breast Augmentation each year in the US alone. It is the safest and most effective means of enlarging the breasts available, but even FDA approved devices, like Breast Implants, need touch-ups from time-to-time.

Do I Need Breast Implant Revision Surgery?

The following Breast Implant Revision Surgery Video originally aired on the San Francisco Bay Area‘s news Station, KRON 4. It reviews Breast Augmentation Revision Options and describes some of the most common breast augmentation revisions. Multiple before and after pictures are included as examples.

Breast Augmentation Revision Surgery Video

Breast Implant Deflation

The introductory photo for the video above shows deflation of this patient’s left breast implant. For Saline Breast Implants, loss of the breast implant’s shell integrity results in complete deflation and loss of breast augmentation. Replacement of a deflated breast implant can be done with minimal downtime. It is also a good time to consider if your breast implants are the right size, profile or style (saline vs silicone), as there is no better time to replace both implants. In situations like the above, it is extremely helpful if you know what type and size of breast implants you have.

Breast Implant Revision – Bigger

The most common reason for Breast Augmentation Revisions is to go bigger. This is especially common after pregnancy with preexisting breast implants as shown above.

The most common reason for Breast Augmentation Revisions is to go bigger. This is especially common after pregnancy with preexisting breast implants as shown above.

The above Breast Implant Revision Before and After Pictures show two common reasons for revision. The first, and the most common, is to go larger. The second, and often seen after pregnancy with preexisting breast implants, is to correct breast tissue sagging off the breast implants.

This patient has already had a Breast Augmentation Mastopexy, also known as a breast lift, using breast implants for additional volume. The larger the preexisting breast tissue volume, the more likely the breast is to sag. This is true with or without breast implants. She desired larger breasts and a perkier appearance. A larger Breast Implant provides both additional volume and support for her breasts.

Breast Implant Revision – Smaller

The above Breast Augmentation Revision pictures demonstrate the correction of bottoming out.

The above Breast Augmentation Revision pictures demonstrate the correction of bottoming out.

Sometimes, the breast implants are too large to be supported. The before picture, in the above Breast Augmentation Revision Before and After Pictures, demonstrates what happens when breast implants are too large, even with a breast lift. Over time, the Breast Implants have over-stretched the skin of the lower breast and moved down the chest. The previous breast lift (mastopexy) scar is red and irritated, and the nipple is riding high. This patient presented with a desire for correction of the shape of her breasts, and also wanted to be smaller.

The after photo shows the results after the mastopexy was revised and the breast implants were replaced with smaller, lower profile, Breast Implants. The mastopexy scar looks less irritated. The distance between the nipples and the bottom of the breast is reduced to normal. The new breast implants are smaller, but maintain the width of the breast to preserve cleavage.

Breast Implant Revision Surgery Consultations

With the popularity of Breast Implants it is not surprising that Breast Augmentation Revision Surgery has become its own specialty. If you have breast implants which are:

  • too small
  • too large
  • too high
  • too low
  • too close together
  • too far apart
  • too hard
  • deflated or leaking
  • not supporting your breast tissue

then give my San Francisco Bay Area Plastic Surgery Clinic a call at (925) 943-6353. With 20 years of experience, I will give you up-to-date options that are personalized to your unique situation. Previous operative reports and your before and after pictures help, so bring them with you, too.

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