Aaron Stone MD - Plastic Surgery

Controlling Pain After Cosmetic Surgery

noreply@blogger.com (Aaron Stone MD) — Fri, 01 Jun 2012 06:23:00 +0000

Pain control during surgery has been quite good for a number of decades. Refinements in recovery from anesthesia to lower the incidence of nausea, shaking etc. after surgery have been accomplished by adjusting the mix of anesthetics used and employing newer medications like propofol, toradol, zofran etc. More recently the focus has been on controlling pain after surgery to lessen the need for narcotics, shorten recovery times after surgery and improve surgical results in general. The opioid narcotic medications commonly used can become addictive, have small windows between effective and overdosing quantities that affect breathing and tend to be constipating.
Local anesthetics have been in regular use since the late 1800s. Most people currently get their exposure to them at the dentist office where novocaine also called lidocaine is injected prior to dental work. The onset and duration of action varies between different local anesthetics. Novocaine is one of the quickest onset and shortest acting local anesthetics. About 10 years ago surgeons began using longer acting bupivacaine applied via external pumps and tubes like the on-Q system to the operative site as a means of pain control after surgery.

The thought was that slow constant administration of a long acting local anesthetic to the operative site would allow for a quicker recovery after surgery, allow the patient to get up and around earlier and decrease the need for narcotic pain killers after surgery. Their use became especially popular with orthopedic surgeons who would place the catheters directly over bones or into joint spaces after surgery (such as knee or shoulder surgery) and to a lesser extent with general and thoracic surgeons. In 2007 it was discovered that prolonged exposure of joints to local anesthetic caused permanent loss of cartilage in the shoulder joint and multiple lawsuits have been filed since. Currently, there is no effective treatment for cartilage loss; patients who have experienced it have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement. Use among plastic surgeons was more limited and confined mostly to tummy tuck and breast surgery patients to decrease reliance on pain medications and allow for earlier ambulation after surgery. I tried this in the past on tummy tuck patients and was unimpressed by its ability to do either so I stopped doing it.

In October, 2011 the FDA approved Exparel which has just recently become available for public use. Exparel is long acting bupivacaine that has been placed in a container of microscopic fat cells. The anesthetic is then slowly released from the fat cell container into the body after injection. This extends the effectiveness of the anesthetic from a few hours up to 3 days. EXPAREL is the first and only multivesicular liposome-based local anesthetic that can be used around surgery in the same fashion as current local anesthetics. The medication is injected near the end of surgery and should not be injected with other local anesthetics at the same time as that could result in sudden release of all of the anesthetic from the fat cell containers. In clinical studies exparel was most effective in the first 24 hours after surgery. The fat cell containers can be damaged by contact with the liquid antiseptics commonly used just prior to surgery.

Due to the large surface areas involved in body contouring surgery like breast surgery and abdominoplasty I suspect this medication will prove most useful for rhinoplasty, facial implant, ear and hand surgery. Clinical studies have shown this medication to be most effective in the first 24 hours after surgery and to significantly reduce the need for narcotic pain medications after surgery.

I think we will see many more fat cell packaged medications in the future.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Liposuction Can Result in More Fat Around Internal Organs

noreply@blogger.com (Aaron Stone MD) — Thu, 17 May 2012 00:31:00 +0000

Plastic Surgeon researchers at the University of Sao Paulo in Brazil followed 36 normal-weight women who had liposuction to take away a small amount of superficial tummy fat. Beginning 2 months after surgery half of these women were placed on an exercise program (walking on a treadmill and doing light strength training 3 times a week), while the rest stuck with their usual lifestyle. None exercised regularly before surgery.

Four months later the women who did not exercise still had flatter tummies, but they had 10% more fat around the organs inside the abdomen. The women who did exercise had no such gain in this visceral fat. Visceral fat is particularly undesirable because it's more closely connected to the risks of type 2 diabetes and heart disease, versus the superficial abdominal fat just under the skin. This the the first study showing increases in visceral fat after liposuction if you do not exercise.

You can also conclude from this that patients who are obese and try liposuction for weight control are actually endangering their health if they do not exercise or change their diets after liposuction because they will end up with even more fat around their organs. The best candidates for liposuction are normal weight to moderately overweight, and already regularly exercise. It is very important, if not essential, that patients exercise after liposuction.

In the U.S., about 204,700 people underwent liposuction in 2011, according to the American Society of Plastic Surgeons. That was down 42 percent from a decade before.
Aaron Stone MD - Plastic Surgeon Los Angeles
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Botox, Xeomin and Corporate Espionage

noreply@blogger.com (Aaron Stone MD) — Fri, 23 Mar 2012 00:43:00 +0000

On Friday, March 9, US District Judge Andrew Guilford entered an injunction against Merz Pharmaceuticals in his Santa Ana, California court chambers. This prohibits Merz from selling filler products or Xeomin or soliciting the purchase of filler products or Xeomin in the facial aesthetic market for 10 months from the date of the order, except in limited circumstances. Merz has to also do a number of other things and report on these to the court in 6 month intervals for the next year in a half. This took place about a week before Merz was supposed to introduce Xeomin, a new direct competitor to Botox, at a major medical meeting in the US.

The FDA approved Merz Pharmaceutical's, Xeomin, in July 2010, which would compete with Allergan’s Botox in the treatment of facial wrinkles. Merz then began hiring employees in anticipation of selling Xeomin nationwide. The problem was they hired employees directly away from Allergan. These employees came to Merz with extensive knowledge and experience in the sale of Botox and Allergan's injectable fillers including sales lists, sales strategies, market analysis, competitive analysis etc. Reportedly, some Allergan employees signed contracts with Merz and then delayed giving final notice so they could e-mail company data to themselves. Allergan promptly initiated legal action on August 4, 2010 as hundreds of millions of dollars in sales per year were at stake.

In response to this a Merz lawyer gave all sales representatives a presentation on compliance and confidential information at a national sales meeting on August 5, 2010. In this presentation, they were told, “Merz aesthetic prohibits employees from disclosing confidential/proprietary information of previous employers.” However, only 3 days before this, a regional sales manager for Merz sent out an e-mail that said: “Competitive info- For those of you coming from a competitor or former competitor, please give as much info as you can on KOL’S” (Key Opinion Leaders) sales numbers, office volume, product info etc… (SIC) this will be very valuable for everybody in the region.” The e-mail then noted that all of the recipients had been blind courtesy copied "...so that [they] would remain anonymous and exit [their] current positions without any problem." Eight days later, Merz's regional sales representative received Allergan documents labeled “For Internal Use Only” and “For Your Information Only. Do Not Duplicate, Detail, Distribute, or Use in Any Promotional Manner.” If this is not corporate espionage resulting in the looting of Allergan’s confidential and propriety information I do not know what is.

That means Xeomin will not be available to the general public until 2013 and Judge Guilford’s order will likely not put an end to this litigation. Furthermore a 12-month ban on Xeomin sales could put Merz out of business. The real losers in this battle are the medical community and the general public as an effective medication that has been FDA-approved and has both aesthetic and therapeutic value will be withheld for many months to come leaving Allergan with a near monopoly market position.

Allergan also prevailed in two separate cases that were filed against Merz in Europe. In Germany, the Hamburg Regional Court ruled that Merz is prohibited from claiming a 1:1 dose equivalent ratio between units of Botox (onabotulinumtoxinA) and Xeomin. In Spain, Merz was found to be in breach of the Spanish Pharmaceutical Code for referring to a conversion ratio without making an express warning about the fact that the unit doses are not interchangeable.

William D. Humphries, CEO of Merz Inc, state "We regret that this ruling will affect physicians and patients as we believe that access to quality FDA-approved treatment options, including Xeomin, is a cornerstone of the US market. It is critical at this juncture to clarify that this lawsuit, which is commercial in nature and focuses specifically on alleged trade secrets, did not call into question the quality of Xeomin."

Full compliance may allow for injunctive relief, at least in the US, after specific criteria are met, and enable the Merz to launch of XEOMIN in the US market.

Julio L. Garcia, M.D, a Las Vegas plastic surgeon, filed suit against Botox-maker Allergan at the end of 2011, claiming the Irvine California-based company sold the drug in large vials and encouraged physicians to unsafely reuse them. He contends that even though a typical Botox (onabotulinumtoxinA) treatment requires just 20 units, Allergan sold the drug exclusively in 100-unit vials for several years and that its sales reps encouraged physicians to use the vials on multiple patients. That practice is now condemned by the Centers for Disease Control and Prevention and state health agencies even though the majority of doctors still use a single vial on more than one patient. The suit, filed at the United States District Court, Central District of California, claims Allergan started selling Botox in 50-unit vials in 2008 “only after the hepatitis exposure in Nevada,” and that even with that revised packaging, the majority of the medication must be discarded after use, keeping costs and manufacturer profits high. Despite the common multiple patient use of vials a large amount of the medication is discarded daily because the shelf after reconstitution is only a few weeks.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Treatment of Aging Hands

noreply@blogger.com (Aaron Stone MD) — Sun, 18 Mar 2012 04:50:00 +0000

As you get older your hands lose fat and muscle volume. The skin develops brown spots (liver spots also know as sun spots), becomes more translucent and shriveled, thins and loses its elasticity. The skin doesn’t bounce back when you pinch it. The underlying veins, tendons and bones then become more visible.

Although we have botox, injectable fillers and facelifts to make our faces look younger as we age the hands frequently look much older than our treated faces. Joan Rivers, no stranger to plastic surgery, suggested to The Huffington Post after Madonna’s recent Super Bowl performance that she favored fingerless gloves because “she’s trying to hide those wrinkly old hands.” Madonna now usually makes public appearances wearing gloves.

The actress Sarah Jessica Parker has a similar aging hand look.

We cannot use botox or removal of the thinned inelastic skin to make our hands look younger. The first is not effective and the second leaves visible scars without solving any of the problems.

We now have options to rejuvenate aging hands. Injectable fillers like Radiesse, Juvéderm, Perlane and Sculptra and of course injections of fat from other areas of the body into the hands are increasingly being used to return volume to the hands. As with any filler, potential complications exist, including infection, skin discoloration, nodule or granuloma formation, asymmetry and skin necrosis so you need to choose your doctor wisely for these treatments. The level of injection and avoidance of blood vessels is crucial when injection fillers into the hands. I prefer injection of fat over other materials. Intense pulsed light, Q switched lasers and CO2 laser resurfacing (including fractional lasers) are used to remove sun spots.

The most important thing is to prevent early aging of the hands by applying sunscreen regularly.
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Aaron Stone MD - Plastic Surgeon Los Angeles
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Documentary of Plastic Surgeon Volunteer Treatment of Acid Burn Victims Wins Academy Award

noreply@blogger.com (Aaron Stone MD) — Tue, 28 Feb 2012 20:17:00 +0000

Sharmeen Obaid-Chinoy was born in Karachi Pakistan, emigrated to Toronto, Canada and this passed weekend won an academy award here in Los Angeles for her short documentary film Saving Face. The film documents the plight of Pakistani women who are disfigured by having acid poured on them usually by relatives, husbands or rejected suitors. The acid damages the skin, sometimes exposes the underlying bones and often times causes blindness in one or both eyes. The film chronicles the efforts of a Pakistani born British plastic surgeon, Mohammad Jawad, to reconstruct their faces and restore their dignity. It is the first win for a Pakistani film. A win that instills pride and shame at the same time. Over 100 such attacks occur in Pakistan each year. Most go unreported and the women live secluded lives due to the circumstances surrounding these attacks (in the case of husband attackers they do so out of fear for their children) so the number of victims could even be double that. In the course of the film a girl describes being burned at age 13 for rejecting the advances of her teacher. In the Western world that teacher would have been prosecuted. Although it is rare a female Pakistani lawyer took up the legal case of one of the victims in the film and successfully managed to have the perpetrator convicted. Sadly these women require multiple operations to regain some resemblance of normal appearance. There is a report of a New Delhi India girl who underwent 25 reconstructive operations to treat disfiguring from acid burns.

The woman in the trailer with the severely disfigured face had acid thrown on her face by her husband after she had filed for divorce. It was almost as if half her face was wiped out. What was left was one eye, half a nose and a mouth that couldn't smile. The prosthetic face mask she was fitted with was voluntarily made by Dubai-based Indian anaplastologist Daril B. Atkins

The film will debut on HBO television March 8, 2012.

A few random such attacks have occurred in the West such as the 2008 attack of a London England model and TV presenter Kate Piper who sustained an acid burn of the face inflicted by an ex-boyfriend and his accomplice. Those 2 men are now serving life sentences in a British prison. Pakistan's Lower House of Parliament unanimously ratified the Acid Control and Acid Crime Prevention Bill On May 10, 2011. The bill calls for life imprisonment of assailants but to date prosecutions have been minimal.

Pakistan's prime minister, Yusuf Raza Gilani, said Pakistan would confer on Obaid-Chinoy "the highest civilian award upon her return".

"Pakistan is reportedly the third-most dangerous country in the world for women after Afghanistan and Congo...". It was only a few years ago that there was a Time magazine cover photo of a young Afghan woman whose nose was cut off in retribution for a similar attack.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Woman's Body Swallows Breast Implant

noreply@blogger.com (Aaron Stone MD) — Sun, 19 Feb 2012 06:09:00 +0000

A report from Johns Hopkins University in the December 2011 New England Journal of Medicine describes the swallowing of a breast implant into a woman's chest cavity. The patient had reconstruction of both breasts after mastectomy for breast cancer. She subsequently had minimally invasive heart surgery via the right mastectomy scar. Some time later while partaking in a Pilates class the right implant was swallowed by her body during a stretching exercise. The intact implant squeezed through a small hole between her ribs left from the heart surgery and ended up on top of her right diaphragm. It must have been scary to look down and see the implant disappear into her chest.

The implant was retrieved, the hole in the chest was closed with a mesh patch and the implant was put back in its original position. Now I assume she is back doing Pilates. This is one thing you don't see everyday.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Home Laser and Cosmetic Devices

noreply@blogger.com (Aaron Stone MD) — Tue, 31 Jan 2012 23:20:00 +0000

A Google search on "home laser" yielded 154,000,000 website links overseas and 48,000,000 when searched in the US. Most of the initial listings are for hair removal devices but there are also ones for treating acne and for facial rejuvenation and others treat skin conditions like psoriasis, vitiligo and dermatitis. Many of these home laser and light or ultrasonic devices can be purchased on the Internet. Sellers tout the benefits of these products in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions. However, few of the devices have been studied or approved by the Food and Drug Administration. Some of them sound sort of scary and could be a waste of money or at worst harmful. Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015. Women have been removing hair from their legs for quite some time. Now it is a multibillion dollar per year industry.

These new home devices tend to fall into four categories:

Diode or intense pulsed light devices that target hair removal,
Light-emitting diode (LED) or heat devices that claim benefits for acne treatment
Rejuvenation devices to treat wrinkles using laser or infrared light
Home phototherapy devices that provide UVB light.

Home devices use lower fluences and longer pulse widths (lower power and less penetration), compared with office-based treatments.

Hair Removal Devices
To be effective, energy in the form of heat must be absorbed by the hair shaft, penetrate deep enough to affect the follicle or root of the hair, and be administered quickly enough to stop transference of the heat to skin surrounding the hair follicle and shaft. Since hair grows in cycles and is most sensitive to treatments during the active growth cycle, it takes several laser treatments to remove hair for good. All of the devices work best and are safest on dark hair in the presence of light skin color.

One of the first home laser devices to be studied was the Tria diode laser.

Studies showed average hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). A skin color sensor blocks the device on darker skin colors otherwise these individuals will form skin blisters. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. It also has a built-in Skin Color Sensor that locks the device on darker skin tones.

It is FDA approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair in the armpit or groin areas (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! Hair device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft without a light so they claim it is safe for all skin and hair colors.

It is the most heavily advertised hair removal device at least on late night television. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).
The No! No! costs approximately $270.

Devices to Treat Acne
Eight studies since 1999 have shown that doctors' office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria the causative agent of acne. Just clearing the bacteria isn’t enough a lot of the time because the bacteria produce irritating proteins that can be left behind so additional medical treatment with prescription or over the counter medications is frequently required. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Four home devices now offer self-application of this blue light. The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day.

The TRIA Skin Perfecting Blue Light uses blue light to kill bacteria in the pores thereby unclogging the pores and eliminating break outs.

Studies have showed 70% clearance of treated areas within 2 weeks. A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602). The device's blue light cartridge has to be replaced about every 2 months. The FDA approved the device for the treatment of acne, it costs approximately $245.

The No! No! Skin uses heat generated by light to treat acne. A green light releases oxygen from porphyrins produced by the bacteria to kill the bacteria. A red light diminishes pain and swelling.

It also costs about $270.

The Claro home device by Sephora

combines heat and intense pulsed light:
-Blue Light (400-430nm): stimulates the production of oxygen, which attacks the bacteria that causes acne
- Red Light (600nm): combines with heat to soothe the inflammation, redness and soreness of each pimple while accelerating the healing process
- Infra-Red Energy (700nm): creates heat that helps to kill the acne bacteria while increasing the effectiveness of blue light
It costs approximately $195 and comes in 3 colors - red, black and blue.

ThermaClear Acne Clearing Device delivers a 2-second pulse of targeted heat to each pimple to kill acne causing bacteria.

It's FDA cleared and advertised as safe and effective on all skin types and tones.

Zeno uses the combination of a topical medication containing 1% salicylic acid and skin moisturizer followed by the application of a small vibrating heat generating hand held device to treat acne.

At $40 it may be the cheapest device available.

Skin Wrinkle Removal - Rejuvenation
The PaloVia fractionated laser (Palomar Medical Technologies) was the first FDA-cleared at-home laser for treating wrinkles around the eyes.

There are two phases to the wrinkle treatment plan – the Initial Phase of one treatment per day for 30 days and the Maintenance Phase of one treatment 2 times per week. It costs about $500. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis.

It directs concentrated ultraviolet B (UVB) light, which has a long history in treating psoriasis, to psoriasis plaques. The treatments require a prescription and programming of the device. Multiple studies have shown that home UVB therapy is as effective as office treatments.

I have not covered the scarier sounding devices in this blog. In conclusion I think we will see doctors doing laser hair removal as a thing of the past. It makes we wonder if the home laser tattoo removal kit is just around the corner.

Laser Skin Resurfacing - Skin Wrinkle Removal
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Slap Your Way to Larger Breasts

noreply@blogger.com (Aaron Stone MD) — Sun, 01 Jan 2012 04:56:00 +0000

35 year old Bangkok, Thailand beautician Khemmika Na Songkhla also known as Khunying Tobnom claims to be able to enlarge your breasts without surgery—by slapping them. Her grandmother mocked her for wasting time rubbing her nipples with a miracle cream when she was in her early teens in hopes of sprouting big breasts. Her grandmother then advised her to rub them till they hurt and repeatedly push fat from her sides and abdomen towards her chest, and then douse the breasts with ice water. She claims that by following her grandmother's advice she boosted her breast size by 4inches and her confidence soared. Ms Khemmikka says that by using this non-surgical technique (squeezing, pinching and slapping fat and muscle on the upper chest, the sides of the torso, and the belly of clients with cream or gel for an hour over six 10-minute sessions for a total cost of $380) she has enlarged the breasts up to 4 inches in thousands of Thai women over the past 14 years without injections, chemicals or implants. After the treatment Khemmika instructs her customers in special exercise techniques and massage to keep their breasts in shape.

Her customers come from a wide range of backgrounds, ages and professions including college girls in their early 20s, a 70-year-old retiree, models, actresses and politicians. “These women once had chicken-egg size breasts. After the course, they have become ostrich egg size,” she says. She turns down customers who are too skinny or do not have much fat on their upper chest or sides of their torso and advises them to gain weight before returning.

She claims that she does not need to advertise as she is living proof of the procedure but a billboard in front of her house-cum-clinic in a suburb of Bangkok reads “beat small busts to be big.” She has been pursuing a patent for her grandmother’s secret fat-kneading technique.

A distraught client claimed that her breast cancer was caused by the slapping technique so Ms Khemmikka asked the Health Ministry to investigate the allegation. The ministry then launched a six -month study on volunteers aged 20 to 60, and found vigorous massage left their breasts cancer-free and measurably bigger or should I say swollen.

Dr. Pennapa Subcharoen, head of the Public Health Ministry’s Thai traditional medicine institute, said Khemmika’s methods were equivalent to the exercises used by body builders. “It is like men going to a gym to build specific parts of their bodies by lifting weights with that part”. I personally do not see the connection and have never seen anyone in the gym slapping themselves to get bigger muscles. Despite that the technique was approved by Thailand's government health board in 2003 as a natural alternative to surgery.

Khemmika also records her clients’ original breast sizes before their treatments, then records their new sizes after the treatments, and lo and behold, a woman with a 30-inch bust should end up with a 32-inch bust by the end of it all. Two whole inches? Wow.

Breast slapping can be relaxing, stimulating and painful. Khemmika’s clients say it hurts.

Interestingly, slapping isn’t just for breasts, either. Khemmika offers slapping treatments for the whole body, including faces. Khemmika considers slapping to be valuable knowledge—she learned it from her grandmother, and apparently no one else in the world knows how to do it but she can teach you how to do it. The application process for enrollment in the classes is lengthy, and the prices of the classes themselves are high: $330,000 for body-sculpting; $260,000 for breast-slapping; and $165,000 for face-slapping. She’s had 40 applicants for these classes, but so far she’s only accepted 4 of them.

Go book your ticket to Thailand now!

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PIP Silicone Breast Implant Recall

noreply@blogger.com (Aaron Stone MD) — Wed, 28 Dec 2011 08:11:00 +0000

The French company Poly Implant Prothese, or PIP manufactured breast implants and supplied a large portion of the European breast implant market. The company was based in the south of France and for awhile was the number 3 breast implant producer in the world. 80% of production was exported out of France. While having undisclosed financial problems it began to cut costs by using a cheaper industrial grade silicone in the implants rather than medical grade silicone. This cut manufacturing costs by up to euro 1 million ($1.3 million) a year. A lawyer for the company told authorities that the switch to cheaper silicone began in 1991, shortly after the company began production. These implants were also marketed under the name M-implant by the company Rofil Medical in the Netherlands and distributed in Germany by the company Rofil Medro. Affected Rofil implants are designated as IMGHC-TX, MX-IMGHC, and IMGHC-LS.

The company was closed in 2010 after its improprieties were discovered following reports by surgeons of excessively high rupture rates and an anonymous letter denouncing company manufacturing processes but by then it had produced and sold over 300,000 implants worldwide including France (30,000), Portugal (2,000), Denmark (less than 100), Spain, Italy, Britain (40,000), Brazil (25,000), Venezuela, Australia (8,900), Chile, etc. Recent studies by the French authorities determined a rupture rate of 11.1% for PIP implants vs. 2% for other implants over the same time period. The durability of the PIP/Rofil implants is therefore substandard and the rupture rate is 5 to 6 times higher than other implants. This is particularly problematic given the use of industrial grade silicone which incites a greater inflammatory response from tissue than medial grade silicone. Between 2007 and 2009 50 to 58 percent of its exports went to South American countries including Venezuela, Brazil, Colombia and Argentina. In the same period, 27 to 28 percent of exports went to western European nations including Britain, Spain, Italy and Germany. These implants were never approved for use in the United States.

PIP saline-filled implants were available in the United States but the authorization was revoked after a re-evaluation by the Food and Drug Administration in 2000 found 11 deviations from ‘good manufacturing practices’ including PIP's failure to investigate the deflation of its saline implants and a failure to report more than 120 complaints in France and elsewhere to the FDA. 35,000 PIP saline implants had already been implanted in the US by that time. I suspect there were also some issues with the shell surrounding these implants as in the past when I held them in my hands the shells seemed flimsy.

More than 1,000 of the 30,000 such implants in France have burst, according to the French health safety agency AFSSAPS. It is now estimated that these implants have double the rupture rate of implants manufactured by other companies. In April 2010 Argentina, Colombia and Brazil banned importation of the implants. More than 2,000 legal complaints have been filed since the implants were recalled in 2010. The liquidation of the company and subsequent loss of company assets means the only remaining lawsuit defendants though are the surgeons who placed them or the government agencies that allowed their use. French authorities have advised all women with the implants to have them replaced but stated the removal was not urgent. They set up a hotline in France that received 9,500 calls between the end of November and December 2011.

It is unclear yet if company founder Jean-Claude Mas will be charged but I suspect there is some jail time in his future. Interpol is currently has a warrant for his arrest. To my shock they even set up a cheaper industrial grade and more expensive medical grade silicone implant to differentiate between lower socioeconomic and higher socioeconomic customers. I suspect the French national health care system will cover removal of all of the implants but not for replacement of those placed for cosmetic reasons. I do not think they currently have the money or enough surgeons though to perform all of the resulting operations. Venezuela has already said it will remove the PIP implants at not cost to patients. They just have to show up at their nearest hospital with a Plastic Surgery ward. It is currently unclear what other Governments around Europe (Britain, Italy, Spain, Denmark..) will do. Given the group speak of Europe at present the other countries will have to fall in behind France's decision and since they also all have nationalized health care those governments will have to spend the money to remove the implants. Money which they do not have!

The Italian association of plastic surgeons is suing the Poly Implant Prothèse (PIP) company as well as TUV Rheinland, the German certification company that inspected these implants. The association states that their surgeons who placed these implants were misled by TUV Rheinland because their substandard inspection left the implants with the European Union's mark of approval.

The International Society for Aesthetic Plastic Surgery was informed by the German authorities at the BfArM Institute that the former company, GfE Medizintechnik GmbH, sold implants that were manufactured using PIP’s industrial-grade silicone gel under the name TiBREEZE between September 2003 and August 2004. These authorities now state that TiBREEZE implants should also be removed even in the absence of symptoms. Most of those implants were sold in Germany to about 280 patients. In addition, TiBREEZE implants were delivered to Belgium, Italy, Finland, South Africa, Switzerland, England, Austria, and Lichtenstein.

Several executives of the company are being sent to trial next year on charges of fraud that carry potential sentences of five years in jail. Names have not thus far been made public.

The World Health Organization has posted a webpage that links to the specific recommendations by national regulatory authorities of countries around the world listed by country with each posted in the native language of that country.

March 15, 2012 Addendum:
Dutch authorities today advised women who have PIP implants made before 2001 to have them removed because they may leak silicone that could harm their health. In the wake of PIP scandal Brazil authorities temporarily banned the import of all breast implants while they work out a testing process for imported breast implants.

April 20 , 2012 Addendum:
Ultrasound studies on 453 women who have PIP breast implsnts in place has shown that as many as one in three of the implants burst within 12 years of being implanted, some without outward physical signs of rupture. That would mean the PIP implants are 15 times more likely to rupture than non-PIP implants. Therefore one can only conclude that all of them should be removed before they become obviously symptomatiuc.
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Dynamic vs. Static Wrinkles

noreply@blogger.com (Aaron Stone MD) — Wed, 14 Dec 2011 22:58:00 +0000

This is a guest post by Stacie Morris, a writer for Botox Ottawa. Stacie’s primary concern? Wrinkles, of course! Her favourite treatment is a customized skincare regimen at home (which includes peptide-rich products) and Botox.

Did you know that there are two types of wrinkles on your face? You’ve got dynamic and static wrinkles.

Dynamic Wrinkles
Remember when you were younger, and your facial skin was pretty much smooth all over when you weren’t expressing any emotion at all? When your face was neutral, your skin had no trace of crease or line. But as soon as your facial muscles contracted to allow the conveying of an expression, like smiling and frowning, a wrinkle appeared. When your facial muscles contract, the skin overlying them stretches and creases to accommodate their movement.

Now that you’re older, you’ll probably notice that the wrinkles that only appeared when you formed an expression are now permanent. This is a natural part of the aging process, as your skin can no longer bounce back from the repeated creasing caused by muscle contractions. These creases in your skin, resulting from the contractions of your muscles, are known as dynamic wrinkles.

Areas on your face most prone to dynamic wrinkles are those that are located where your muscles are most active. These tend to be across the forehead (frowning and surprised expressions), between your eyebrows (frowning), and at the outer corners of your eyes (squinting, smiling, laughing, frowning). The area around your eyes is particularly vulnerable to dynamic wrinkles because not only do we use our eyes pretty much at every waking moment, the skin here is far thinner and sensitive and the rest of your face.

Static Wrinkles
Any wrinkles or creases that are visible even when your face is absolutely neutral and at rest are considered static. Static wrinkles are the result of the natural disintegration of essential components in the skin that are responsible for maintaining structural integrity. These include collagen, elastin, and hyaluronic acid, and all deplete with aging. Environmental factors, such as UV exposure, can accelerate disintegration. Neglected dynamic wrinkles left on their own eventually become static wrinkles.

So what can you do about it?

For the best course of treatment, you should first, determine the type of wrinkle you’d like to eliminate or minimize. If it’s dynamic, you may want to consider something that effectively and safely impacts the mobility of the muscles responsible without being dangerous or unnatural. A treatment such as BOTOX can help especially if the wrinkle completely disappears when the skin on either side of it is pulled away from the wrinkle.

Static wrinkles may be effectively treated with something that replaces lost volume and suppleness, such as injectable fillers. Even a customized skincare regimen can help, but make sure it features products containing beneficial ingredients, such as Retin A, peptides, and stabilized Vitamin C (ascorbic acid).

Aaron Stone MD - Plastic Surgeon Los Angeles
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Asthma - Reversible Lung Disease and Cosmetic Surgery

noreply@blogger.com (Aaron Stone MD) — Tue, 22 Nov 2011 00:15:00 +0000

Obstruction to airflow in the lungs can be due to

fixed or irreversible lung disease (COPD)
reversible (responsive to medications) obstruction due to heart failure
reversible (responsive to medications) obstruction due to asthma

The obstruction can be due to just one of the factors or any combination of 2 or more factors.

In asthma the walls of the breathing tubes into the lungs swell (become inflamed), muscles surrounding the tubes contract squeezing the tubes and then increased mucus secretions inside those tubes plugs them. This results in obstruction to airflow with audible wheezing and a tight feeling in the chest as the individual tries to get the air through narrowed plugged tubes. Attacks can be mild resolving quickly with medication or severe and life threatening.

Attacks of asthma can be stimulated or triggered by environmental factors like pollen, cigarette smoke, dust mites, pet hair, insect excretions, air pollution, stress, exercise, infections etc. The trigger can be something you are allergic to. The primary medications used to treat asthma are bronchodilators which counteract the muscle spasm and steroids which treat the inflammation.

For the asthmatic undergoing cosmetic surgery an attack can be triggered by irritation from the breathing tube in general anesthesia, dehydration associated with any surgery, inability to clear secretions while lying down under the influence of anesthesia or even pain medications used during surgery. The anesthesia staff needs to adjust the medications given in such situations and the patient needs to bring their inhaler with them to surgery, if they have one. If they patient smokes it is imperative that they not do so for at least one week prior to surgery. Cosmetic surgery in an asthmatic who was smoking within days of surgery is a dangerous combination as they are very sensitive to asthmatic triggers.

Abdominoplasty and belt lipectomy patients who are asthmatics are at higher risk of attacks because the immobility after surgery combined with greater pain medication needs.

The steroids used to treat inflammation in asthmatics also prolong the healing process so sutures may have to stay in longer than they otherwise would. The adverse affect on healing can be reversed by taking Vitamin A before and after surgery. The vitamin does not affect the anti-inflammatory effect so it will not exacerbate the asthma.

This is a tricky situation because even if normal lung function tests and a normal physical examination an asthmatic attack can occur due to any of the factors mentioned above. Furthermore, significant impairment of lung function can occur in asthmatics without symptoms. The history and general physical examination may not accurately indicate the severity of the asthma. The answer is not to just do the surgery under local because you think it would be safer. If you have an asthmatic attack induced by a cosmetic procedure and cannot have a breathing tube placed because of the spasm you will not survive. The answer is to do the surgery in an environment where should any of these problems arise the right personnel and equipment are present to handle the situation. Certified operating rooms will have the necessary oxygen, IV fluids, inhaled and injectable bronchodilators, oral and intravenous anti-inflammatory agents to treat an attack. It is highly unlikely that a non-certified operating room will have those medications.

Only asthmatics with stage I disease and an forced expiratory volume greater than 75% of predicted values can undergo surgery without a higher than normal risk of airway complications. Any asthmatic who has taken steroids, whether orally as a pill or as an inhaled medication, within 6 months of surgery needs perioperative steroids to cover for diminished adrenal function. Inhaled steroid medications may have to be temporarily replaced by oral prednisone until the patient has recovered from surgery. Any asthmatic with audible wheezing should not be having elective non-emergent surgery.

I am personally aware of a fit individual in his 30s who went to a martial arts practice session without his inhaler. He suddenly developed an exercise induced asthmatic attack. By the time the ambulance and paramedics had arrived he could not be revived and passed away. Prompt use of an inhaler would most likely have circumvented this. A similar situation could just have easily occurred with cosmetic surgery.

I was performing non-cosmetic reconstructive surgery on a healthy 20 year old patient in the hospital. He was asleep on the table and just as I was about to make the first cut the monitors showed the oxygen in his blood suddenly dropped to dangerously low levels. Anesthesia went into action and gave him a bronchodilator using an inhaler via the breathing tube. He rapidly responded and the oxygen came back to normal levels and was maintained there using intravenous medications. In a non-accredited operating room lacking all of the necessary equipment and medications that patient would have been in real deadly trouble. There is a good chance he would not have survived a liposuction procedure under local anesthesia in a non-certified operating room. Furthermore, that patient was previously thought to be healthy and had no previous history of asthma.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Tips for Bikini Line Laser Hair Removal

noreply@blogger.com (Aaron Stone MD) — Wed, 19 Oct 2011 22:58:00 +0000

This is a guest post by Sachin from the Cosmos Clinic in Sydney Australia

Laser hair removal is a great way to get rid of hair on the bikini line, so follow these tips for the best results!

Are you tired of shaving your bikini line and seeing those red bumps and black spots? Does the idea of waxing down there seem way too painful to be worth it? Then you might want to look into Candela laser hair removal for your bikini line. Here are some general tips to choose a clinic, prepare for the removal and maintain the results.

1. Choose a physician with experience

When choosing a clinic, go for those who have a doctor on staff and have a long experience in laser hair removal. Practitioners with longer experience are better at evaluating your skin tone and hair thickness and density to give you the best possible treatment. It’s especially important with the bikini line because the skin is more sensitive there than on other parts of the body.

2. Discuss the treatment before making your appointment

Don’t give in to pressure to get an appointment right away and ask to meet a practitioner before you commit. Laser hair removal, especially for the bikini line, is costly and may require several visits, so make sure you trust the doctor and feel comfortable at the clinic.

Ask questions about the light type, the length of the treatment, the hair cycle, etc. The better informed you are beforehand the more likely you are to be satisfied with your results.

3. Have realistic expectations

Contrary to popular belief, laser hair removal is not permanent. Hair does regrow, however thinner and slower. Going to the clinic and expecting all your hair to be gone after one treatment is sure to lead you to disappointment.

During your preliminary appointment, discuss your expectations with the doctor. He or she will explain the procedure in more detail.

4. Avoid shaving or waxing too close to your appointment

In order to work properly, the laser machine requires a certain length of hair. If you shave or wax right before your treatment, the machine might not have enough to find the hair follicle.

To prepare for your appointment, follow your clinic’s instructions. They will have all the information you need to make your treatment as painless and easy as possible.

5. Be ready for return visits

Because the hair growth cycle isn’t uniform with all hair, you will probably need a few visits to get the most out of laser hair removal. This is because hair is better removed at a specific time in the hair growth cycle.

To get all the hair at this specific period, then, you may need to visit your clinic more than once. The usual number of treatments varies between five and ten, but it may be different for you.

6. If in doubt, abstain

If you think that laser hair removal might not be for you (if you have dark hair on dark skin or pale hair on pale skin or have a skin condition), don’t be afraid to say no. Don’t spend money on something that won’t be effective for you.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Laser and Intense Pulsed Light (IPL) Safety

noreply@blogger.com (Aaron Stone MD) — Fri, 07 Oct 2011 15:17:00 +0000

Different wavelengths of light penetrate to different depths below the skin surface and are absorbed by different skin or tissue components. For example CO2 and Erbium laser light is absorbed by the water in cells exposed to it. Flahslamp laser light is absorbed by red blood cells. Nd:Yag laser light is absorbed by skin pigment cell melanin and tattoo pigment. Since the eyes contain water, pigment cells, red blood cells etc they can be damaged if exposed to most laser lights either directly or indirectly (from reflected laser light). Even the laser pointers used by lecturers can damage the eye if pointed directly into the eye. Some lasers such as the CO2 have a beam whose wavelength is not visible by the human eye but they can still cause damage to the eye. The CO2 and Erbium will damage the cornea and surface of the eyeball first. Flashlamp and vascular lasers are absorbed by red blood cells and are the most damaging to the eye as they are absorbed by and damage the retina.

For safe laser use one should never look directly into the laser light source or scattered laser light from reflected surfaces. All laser treatments should be performed in treatment rooms or operating rooms that are not open to the public. All persons in the treatment area must wear protective goggles or glasses with side shields. A laser safety sign should be placed outside the door of these treatment rooms so that nobody inadvertently opens the door and gets eye exposure to the lasers being used. Because of the wide variety of wavelengths used in laser treatments today the goggles have to block the specific wavelengths employed. Goggles that block 1064nm wavelength light used to remove black tatoos will usually not block out 532nm wavelength light used to remove red tattoos. All laser safety goggles have the wavelengths they block written on the edge of the lenses. Whenever I use a laser facility for the first time I check the numbers on the goggles before I give them to the patient or put them on myself. If the laser treatment is applied directly to the eyelids metallic dulled eye shields that look like large contact lenses should be placed directly on the eyeball surface.

Intense Pulsed Light or IPL is basically a strobe light of multiple wavelengths used to treat freckles or uneven skin coloration. Technically it is not a laser but it can still damage the eyes even if the eyelids are closed and the IPL treatment is directed at a freckle on the eyelid skin. There are reports of photophobia, iris defects and inflammatory reaction in the anterior chamber of the eye after such treatments. Irreparable damage of the iris (colored ring around the pupil) is the cause of most these problem.

If you suspect that your eyes have been damaged by a laser or IPL treatment you need to be examined by an Ophthalmologist as soon as possible.

Aaron Stone MD - Plastic Surgeon Los Angeles
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What is Botox?

noreply@blogger.com (Aaron Stone MD) — Tue, 04 Oct 2011 17:53:00 +0000

This is a guest post by Sachin from the Cosmos Clinic in Sydney Australia

Botox here, botox there… it seems that all we hear about these days in the cosmetic surgery industry is botox. Hollywood stars use it, New York socialites swear by it… but what is it? If you’re like me, you don’t want to put something in your body if you don’t know what it’s made of. So I did a little research on botox and I want to share my findings with you.

Composition

Botox is kind of scary: it’s a protein that comes from the clostridium botulinum bacterium. (Botulism is a paralytic disorder caused by poisoning through the aforementioned bacterium. It can be caught in the digestive tract, from food or through contamination of a wound.) Botox is basically the most powerful neurotoxin known to man.

In its current form, Botox is a denatured version of the toxin that can be safely introduced in muscle tissue.

How it got in cosmetic medicine

The medical effects of Botox were first studied for ophthalmic treatments. It was first used to treat strabismus, or “crossed eyes” and uncontrollable blinking.

After the FDA approved botox in 1989, plastic surgeons started using it to treat frown lines between the eyebrows. Trials were conducted and botox was again approved for wrinkle and frown line treatments in 2002.

Since then, there has been an explosion of research about the potential therapeutic uses of this otherwise deadly toxin.

Other uses

Other than for treating wrinkles and frown lines, botox can also be used to treat:
• Muscle spams
• Upper motor neuron syndrome
• Excessive sweating
• Cervical dystonia
• Chronic migraine

How it works

Botox works by applying the paralyzing effect of the toxin locally and in small doses. Wrinkles appear because of muscle tension; botox works by paralyzing or relaxing the offending muscles, thus reducing or smoothing out the wrinkle.

In more scientific terms, botox blocks the brain’s signals to the nerves that control the muscles. It means that your muscle will stop receiving the “order” to contract, since the message can’t make it to your nerve endings.

How it’s used

Botox is injected without any anesthesia. The procedure is quick and mostly painless—only the prick of the needle in your skin.

Botox lasts between 3 and 4 months and up to 6 months, depending your body’s ability to absorb and eliminate the toxin. This means that if you want the effects to last, you need to repeat the injections two to four times a year.

Risks and side effects

Botox is generally safe but there are several side effects, minor and temporary, that may appear. These include allergic reaction to the toxin, bleeding, bruising or loss of sensation.

The idea of using a deadly toxin to reduce the look of wrinkles might be scary, but millions of patients every year use Botox and dermal fillers and very few get any serious side effects. For a quick rejuvenating effect before an important event, it might actually be your best bet! Just remember it takes a few days for the Botox to become effective.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Topical Botox Gel

noreply@blogger.com (Aaron Stone MD) — Fri, 30 Sep 2011 19:59:00 +0000

A new topical gel botulinum toxin (Botox) is currently being studied. This will allow patients to apply the medication topically to erase crow's feet, frown lines and forehead wrinkles without the need for needle injections of Botox. 90% of patients in a phase 2 clinical trial treated with the experimental gel had visible reduction of moderate to sever crow's feet wrinkles compared to 28% of similar patients randomly assigned to a placebo group.

Effects of the gel last for about four months which is comparable to the effective duration of Botox injections.

Phase 3 studies are in the works to compare the gel to injected Botox.

It is not yet known when this will be available for public consumption but I think you will see this as an active ingredient available in cosmetic counter cosmeceuticals in the very near future.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Massive weight loss and breast reduction surgery

noreply@blogger.com (Aaron Stone MD) — Tue, 13 Sep 2011 20:25:00 +0000

Obesity is another term for being overweight. It is medically defined as a weight to body surface ratio (BMI) of 30kg/m2 or more. Morbid obesity is defined as being 100 pounds or more above one's ideal body weight which in turn is defined relative to one's height. This correlates to a BMI of 35 to 45. Higher BMIs are referred to as super obesity. The incidence of obesity in general has been steadily increasing in North America, Australia, Europe, the Middle East and South America (i.e. worldwide) over the last few decades leading to a rise in weight loss surgery procedures performed and profitability of weight loss groups like Weight Watchers, Jenny Craig etc.

The frequency of large breasts and medical problems related to them like back, neck and shoulder pain as well as skin breakdown is of course higher in the obese population. The question that is increasingly coming up for review of health insurance coverage is whether or not patients with higher BMIs should have breast reduction surgery before weight loss surgery or diet/exercise induced weight loss. Having the breast reduction first does relieve the large breast associated pain and does increase the ability of these women to exercise. However, after losing the excess weight almost 90% of these women who had breast surgery first were unhappy with the look of their breasts after the weight loss. Around half of these women said they would have additional surgery to improve the look of their breasts. Had they waited until after the weight loss to perform the breast reduction surgery they most likely would not need a second breast operation. In contrast only 70% of women who only had bariatric weight loss surgery were unhappy with the appearance of their breasts after the weight loss.

Insurance claims data from seven Blue Cross and Blue Shield plans were examined for patients who underwent elective breast procedures (breast reduction, breast reconstruction, breast augmentation, breast lift) covered by insurance between 2002 and 2006. 2,403 patients of these patients were obese and 5,597 were of normal weight. Within 30 days of surgery, 18.3 percent of the obese patients experienced at least once complication, while only 2.2 percent of patients in the control group did so. The differences between the two groups of patients were most pronounced in complications, such as inflammation (with obese patients 22 times more likely to suffer a complication), infection (13 times more likely) and pain (11 times more likely).

My personal feeling is the only elective procedure (that includes cosmetic surgery other than minor procedures) a morbidly or super obese individual should have are weight loss surgery. The risks of surgery in these patients in my clearly outweighs any benefit from the cosmetic procedure. They are prone to complications after surgery and many are malnourished despite being obese so they cannot heal properly.

A morbidly obese patient came to me after her cosmetic abdominoplasty performed by another surgeon reopened and failed to heal. After an examination and diet history it was clear to me that although she was morbidly obese she was also malnourished and therefore could not heal. That surgeon kept placing sutures and prescribing antibiotics for almost 2 months with little change in her condition. After forcing her to change her diet she healed up completely in less than 2 weeks.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Some surgical and non-surgical techniques to treat cellulite.

noreply@blogger.com (Aaron Stone MD) — Fri, 09 Sep 2011 07:08:00 +0000

This is a guest post by Sachin from the Cosmos Clinic in Sydney Australia.

Don’t believe the hype—there is no final cellulite treatment. Nothing but a genetic makeover could get rid of cellulite. Actually, 80 to 90% of women have cellulite at one point in their life, so you’re definitely not alone. But that also gives pharmaceutical companies and cosmetic surgery clinics an enormous clientele pool to help or abuse… depending on what treatment you choose.

While cellulite can’t be completely removed, there are ways to help reduce is appearance and even temporarily drain it away. Here are some of them.

Laser lipolysis

Among the newest treatments in the liposuction line, laser lipolysis proponents claim that using lasers help tighten the skin as well as break up fat cells stuck under the skin, thus improving the appearance of orange peel skin. Traditional liposuction may make cellulite worse, so avoid it as a cellulite treatment. There have not yet been any studies on the effectiveness of laser lipolysis for cellulite treatment.

Acoustic Wave Therapy

Using ultrasound to break up fat in the body is also a relatively new treatment for cellulite, even though it’s been used for a while in liposuction. It’s less invasive as the acoustic wave is applied externally through the skin. Again, no long-term studies have been made but there have been some promising results.

Cellulite subcision surgery

This intervention is rarely used, with limited availability and success. It involves using a v-shaped knife and running it under the skin, cutting the bands of connective tissue that cause cellulite. Thus, the fat is released and can be removed. This is extremely invasive (and thus more dangerous) and cannot be used everywhere on the body.

Lower body lift

This is another invasive intervention that carries the most risks and may produce excessive scarring. It involves cutting excess skin and lifting the remaining skin to lift and tighten the appearance of the abdomen, butt and thighs. It doesn’t get rid of cellulite but can significantly reduce its appearance.

Fat grafting

Fighting fire with fire—or fat with fat: that’s what fat grafting is about. By harvesting fat through liposuction and re-injecting under the skin to smooth it out, fat grafting can help reduce the appearance of cellulite. However it is a temporary measure, as the body usually reabsorbs fat cells.

Endermologie

This patented treatment involves a massage device that supposedly massages water retention, breaks up fat cells and stretch out the connective tissue under the skin. The company also claims that the massage stimulates the production of collagen, thus thickening and strengthening the skin. This treatment is temporary and must be repeated regularly to maintain the effect.

Velasmooth

This is like Endermologie, with added technology of infrared light and radiofrequency waves. It’s also temporary and the results are rather modest.

There is no easy body sculpting solution. Cellulite cannot be gotten rid of only through cosmetic intervention—you must also have a good diet and exercise program. But some of these interventions and products can help smooth away the skin and reduce the dimpled appearance of cellulite.

Cellulite-Cottage Cheese Thighs Aaron Stone MD - Plastic Surgeon Los Angeles
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Bleeding Disorders, Hemophilia, Antithrombin III Deficiency, Aspirin, Abnormal Platelet Count, Anticoagulation and Cosmetic Surgery

noreply@blogger.com (Aaron Stone MD) — Sun, 07 Aug 2011 11:49:00 +0000

Blood clot formation is a complex process involving first the accumulation of cells in the blood called platelets to form a plug and then a number of proteins/enzymes also called clotting factors that act upon one another in a specific sequence one after the other like dominoes dropping called a cascade to form a mesh that reinforces the platelet plug. The end result of which we see and call a clot. The platelets are the white circles in the video below. The cascade allows immense production of clot in a shorter period of time from a small amount of initiating stimulus so it has been programmed into our systems through evolution i.e.the organism that can stop bleeding the quickest after injury has the best chance of surviving. Along the way there are built in inhibitory enzymes at different parts of the cascade so that the cascade does not get out of control and turn your bloodstream into a solid clot.

Normally this clot formation process helps healing after cosmetic surgery and works in the background unnoticed for the benefit of patient and surgeon. It becomes a problem when the blood can form clots too easily or will not form clots or the clots form but are destroyed too quickly by the body. All of these situations can be dangerous for any type of surgery. These conditions can occur because of something the patient was born with, a disease the patient developed, a side effect of certain medications or a vitamin K deficiency. If it is medication induced the patient just stops or substitutes the medication sometime before surgery. In urgent or emergent cases another medication can be given to reverse the action of the first such as vitamin K for coumadin and protamine for helparin. Most of the blood clotting factors are manufactured in the liver so liver disease can result in the loss of this manufacturing ability resulting in a bleeding disorder.

Hemophilia is a classic case of an inability to form clots. It is caused by a deficiency or absence of some of the factors required for the clotting cascade to proceed and is something one is born with. They form the initial platelet plug but then cannot reinforce it. The defective gene is on the X chromosome so XX females tend to be carriers with only one affected X chromosome and their XY male sons can actually have the disease. In these cases the patient only needs to be injected with the missing clotting factors after which they can proceed with cosmetic surgery like any other patient. The injection is given 2 hours before surgery to raise the level of factor to 80% or more of normal and then maintained by additional injections for 10 to 14 days after surgery.

There is another form of hemophilia called Von Willebrand's Disease which involves defects on chromosomes other than the sex chromosomes X and Y. The bleeding tendencies are usually less in these cases than regular hemophilia but the severity of the bleeding disorder is highly variable. These patients have difficulty forming the initial platelet plug. The treatment of choice for mild von Willebrand disease is Stimate® or desmopressin acetate (DDAVP), a nasal spray that stimulates the body to increase factor VIII and von Willebrand levels. It is given to patients to increase the amount of the von Willebrand factor long enough for surgery or dental procedures to be performed. DDAVP is a synthetic product that carries no risk of infectious disease because it is not isolated from the blood of other individuals.

For excessive bleeding in Von Willebrand's Disease, infusions of a factor VIII concentrate rich in von Willebrand factor, such as Humate-P®, Alphanate®, Wilate® or Koate DVI®, may be required. Humate-P, manufactured by CSL-Behring, Alphanate, manufactured by Grifols and Wilate, manufactured by Octapharma are the only FDA-approved Factor VIII concentrate for use in von Willebrand Disease. The level should be raised to 80% or more of normal and maintained at that level for 10 to 14 days after surgery

Aspirin and many of the drugs used for pain can aggravate bleeding because they interfere with platelet function. People who have von Willebrand disease can take tylenol for pain relief because it does not inhibit platelet function. They should avoid any aspirin containing medications.

At the bottom of the cascade prothrombin is converted into thrombin which in turn converts fibrinogen to fibrin. Fibrin is the white hair like strands visible in the video above that form a mesh around the platelet plug so the clot does not come apart. The visible clot that we see with the naked eye consists of multiple fibrin molecules stuck together with cells called platelets that group together to form a plug at the site of injury.

Antithrombin III is a protein in the blood that binds to thrombin or other protein/enzymes at the bottom of the cascade to put the brakes on, stop or slow the clotting cascade. Patients who have antithrombin III deficiency are prone to making too much clot. They form clots in the deep veins of the legs and large veins in the abdomen. This can be precipitated by surgery, trauma, pregnancy, oral contraceptive use, or infection. These patients are given a medication called heparin to increase the activity of whatever amount of antithrombin III is present. Since the 1980s a purified (low molecular weight) heparin has been available that is easier to take and does not have to monitored as closely for overdose. This form can be taken at home instead of being restricted to in hospital use. They can also be given Antithombrin III concentrate to bring the blood levels to normal or close to normal.

Protein C and S inhibit the pathways involved in clot formation specifically at Factor VIII and Factor V. Individuals with genetic deficiencies of these proteins are also more prone to making clot than normal (6 times more so than individuals with normal protein S levels) especially in the veins. Protein S deficiency can be hereditary or due to vitamin K deficiency, sex hormone therapy, liver disease or chronic infections. Inherited Protein S deficiency occurs in 1 in 500 people in the US. Those who also are inactive, have a previous history of blood clots, smoke, are obese or are taking birth control pills are at a very high risk for forming blood clots. Protein S deficient patients therefore need to exercise regularly, stop or never start smoking, control their weight and stay away from birth control pills.

The primary goal in protein S deficient patients is to prevent the first big clot. Once that forms future ones are much more likely to form. Surgery can damage blood vessels stimulating the clotting cascade which in these cases can over react to the surgical stimulus. If the over reaction is severe enough it can be life threatening.

These patients need prophylactic anticoagulation with heparin before, during and after surgery with a hematologist directly involved in their care. In contrast to protein C and antithrombin, there is no purified form of protein S available for clinical use. Therefore surgery in these cases must be done in a hospital in case fresh frozen plasma (FFP) is required in the event that the clotting cascade starts to over react. That is the only way to replenish the Protein S stores. Surgery in an office operating room is not safe for these patients.

Aspirin changes the platelet surface so the platelets cannot stick together to form the initial platelet plug. If a blood vessel is then cut it will continue to leak blood for a prolonged period of time. This is why even removing a skin surface mole can be a problem in patients taking aspirin. Cutting into the skin and performing surgery on deeper structures in patients taking aspirin can be very dangerous. Even liposuction, which involves skin incisions only followed by introduction of a blunt metal tube to remove the fat should not be performed on patients who have recently taken aspirin. It takes 7 to 10 days for your body to make new platelets to replace those that have been altered by aspirin. It is you crucial that you stop any aspirin intake a week or more before any surgery. Even one aspirin in that time frame can cause a problem. The only other way to reverse the effect of aspirin is to transfuse platelets (a blood transfusion). With aspirin use the platelet count will be normal but they do not function properly. The only way to pick this up is by the patient telling the surgeon they took aspirin and by a test called a bleeding time. All the other usual blood tests will be normal.

Bleeding problems can also arise if the number of platelets is too high or too low. This situation can be caused by cancer, infection, chemotherapy, radiation, poisons, medications, nutritional deficiencies... Low platelet counts can be divided into those due to decreased production of platelets and those due to increased destruction of platelets. The normal platelet count is 150,000 to 400,000/mm3. Surgical bleeding becomes a problem with platelet counts less than 50,000/mm3. Spontaneously bleeding occurs at platelet counts less than 10,000/mm3. There are also conditions where the platelet count is very high (above 1,000,000/mm3) that are associated with abnormal bleeding during surgery. In such cases the platelet count has to be lowered before undergoing surgery. The life span of a normal platelet is 10 days. A transfused platelet has a life span of only 4 or 5 days. The treatment for abnormal platelet counts will depend on the cause of the problem.

As I mentioned in a previous blog vitamin E and multiple herbal medications prevent blood from clotting normally and can be very dangerous when combined with surgery.

One of my patients had a history of blood clots in the deep veins of his legs. With the aid of his internist he received low molecular weight heparin around the time of his abdominoplasty and sailed through surgery without complications.

Another patient had a stent placed in a neck artery feeding directly into the brain. She was taking blood thinners to prevent clotting within the stent. Again with the aid of her medical doctors we stopped the blood thinners a week before surgery and started low molecular weight heparin. I removed a skin tumor from her scalp and she went back on the blood thinners a day after surgery.

I reviewed a case where a hemophiliac underwent facelift surgery. That patient was transferred directly from the surgeon's office operating room to a hospital operating room where blood components had to be transfused emergently until the bleeding stopped. After a couple of days in the intensive care unit that patient was sent home.

The bottom line is if there is an intrinsic problem with the ability to form clots cosmetic surgery that could result in significant bleeding should be done in a hospital with a hematologist familiar with the patient readily available. That way should the need arise for transfusing blood components or specialty care they are readily available. Safety during surgery should take precedence over cost of surgery.

Aaron Stone MD - Plastic Surgeon Los Angeles
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Sickle Cell Disease and Cosmetic Surgery

noreply@blogger.com (Aaron Stone MD) — Tue, 19 Jul 2011 23:48:00 +0000

Hemoglobin is the protein in red blood cells that carries oxygen. It is encoded by 2 genes in one's DNA, 1 gene from each parent. Either or both of these genes can have a sickle cell trait so that the hemoglobin produced by either or both as the case may be is abnormal. If only one gene is abnormal the individual is said to have sickle trait. If both are involved the individual has sickle cell disease. The sickle gene is most commonly found in those of sub-Saharan African descent. It is thought that that is because the sickle trait confers resistance to the malaria that is present there. 0.5% of the Afro-American population has both genes and 8% have the trait. Under low oxygen levels the sickle hemoglobin changes shape and makes the red blood cell it is in turn into a sickle shape. Conditions that make the abnormal cells sickle include lowered body temperature, infections, acidic metabolic conditions, dehydration and as mentioned lowered blood oxygen levels. The sickle shaped blood cells have a shorter life span and tend to get caught in the smaller blood vessels of the body. The manifestation of this depends on the percentage of total body red blood cells/hemoglobin that is abnormal. Those with only the trait (one gene) have an easier time. When the percentage is high it is associated with anemia, stunted growth, sores on the legs, heart problems, shortened life span, organ failure etc.

The affect on cosmetic surgery and the measures needed to ensure safe surgery depend on the percentage. At low percentages you do not need to do anything different from other patients. At higher percentages the patient may need pre-surgery treatment with one or more of the following supplemental oxygen, blood transfusion, over-hydration etc. If the percentage is very high the patient should probably not be having elective cosmetic surgery. Your surgeon needs to work together with a hematologist in order to ensure a smooth recovery after surgery.

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Mommy Makeover Abdominoplasty with Pelvic Sling for Urinary Incontinence

noreply@blogger.com (Aaron Stone MD) — Mon, 18 Jul 2011 23:28:00 +0000

Urinary incontinence (leaking of urine) can be problematic and embarrassing for women past their childbearing years. Pregnancy and/or the aging process weakens or damages nerves, muscles and/or their supporting structures in the pelvic area. This results in incontinence (inability to hold back urination). There are different types such as stress incontinence, urgency incontinence etc. After trials of non-surgical treatments such as injection of bulking agents around the urethra (tube extending down from the bladder that urine flows through) have failed sling or bladder neck suspension surgical procedures may be needed to treat stress incontinence.

Sling Procedures for Urinary Incontinence

In the sling procedures a piece of human or animal tissue or a synthetic tape is passed around the urethra and then over the pubic bone. The sling lifts the urethra and changes the angle between it and the bladder so that urine dose not come done the urethra or leak until the bladder contracts in a controlled manner in the bathroom.

Bladder Suspension Procedures for Urinary Incontinence

Suspension procedures involve placing stitches (sutures) in vaginal tissue near the bladder neck (where the urethra and bladder meet) and then passing the stitches to a ligament near the pubic bone (Burch procedure) or in the cartilage of the pubic bone itself (Marshall-Marchetti-Krantz procedure). These sutures reinforce the urethra and bladder neck so that they don't sag.

Urethra Before (Left) and After (Right) a Sling Procedure
Because of social stigma, an estimated 50 to 70% of women with urinary incontinence do not seek medical evaluation and treatment. Only 5% Of women with urinary incontinence in the general population and 2% in nursing homes receive appropriate medical evaluation and treatment. Women with urinary incontinence often endure this condition for 6 to 9 years before seeking medical treatment.

Both types of procedures can be performed via an abdominal incision that can be incorporated into an abdominoplasty procedure.

Some surgeons prefer to do these separately for fear of infection because the bladder procedure involves operating inside the abdomen of abdominal organs. Although that is theoretically correct I have not found that to be a problem. Extra care needs to be taken in order to avoid cross contamination. I have also performed abdominoplasty in conjunction with a tubal ligation and vaginal tightening performed by an OB/GYN and have not had a problem with that procedure either.

Mommy Makeover Surgery - Abdominoplasty
Abdominoplasty - Tummy Tuck
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Plastic Surgery and Mesothelioma Align

noreply@blogger.com (Aaron Stone MD) — Fri, 01 Jul 2011 19:12:00 +0000

This is a guest post by Jackie Clark assistant to Heather Von St James, a cancer survivor.

When someone mentions plastic surgery, we tend to think of face-lifts and breast implants, but plastic surgeons are able too much more. What would burn and accident victims do if there were no plastic surgeons to repair their faces and bodies? What kind of life would a deformed infant have if there were no plastic surgeons to correct nature's mistakes? There are millions of people in the United States alone, not to mention the rest of the world, who feel they were not given the body or face they deserve. Being unhappy with one's looks can cause many problems like depression, low self-esteem and even suicidal tendencies. There are forms of cancer like mesothelioma, breast cancer and skin cancer that can kill if not treated by surgery.

This surgery falls into 3 categories:
1--Reconstructive surgery involving pediatric birth defect surgery, injury repair, burn surgery, hand surgery, breast cancer surgery, adult birth defect correction surgery and other corrective procedures.
These are surgeries that are done for medical reasons and can make life expectancies longer. Repairing accident damage can give people their lives back.

2--Cosmetic surgery includes procedures like tummy tucks, eyelid surgery, breast implants or reduction, buttock augmentation, face lifts, liposuction fat removal, chin implants, chemical peels, lip enhancement, laser treatment, neck lifts, eyebrow lifts and other procedures to enhance a person's looks.

3. Surgery that treats forms of cancer like mesothelioma, skin cancer, breast cancer and other diseases that are life threatening. This is not cosmetic surgery, but surgeons that are able to perform plastic surgery are often also qualified to perform other life saving medical procedures that increase patient life expectancy.

Plastic surgery like any medical procedure carries risks that one should be aware of before making a decision. The risks can range from swelling and bruising to infection, organ punctures, bleeding, scars, fluid accumulation and allergies to anesthesia and other drugs used in the procedures. A good surgeon will go over all the benefits and risks with every patient, taking medical history of each patient to be safe. It is standard procedure for the plastic surgeon to talk about allergies and expectations of results with every potential patient. Anyone considering surgery of any kind should look for a surgeon who is board certified and professionally affiliated as well as being licensed and degreed from a good medical school.

Plastic surgery is not cheap and is not always covered by your insurance provider. If one's life expectancy, health or self-esteem is involved, no price is too high. Specifically concerning a mesothelioma prognosis an operation maybe the only available resource to save ones life or for that matter lengthen it. These medical procedures are more likely to be covered by insurance and costs vary depending on the seriousness of the condition. Before agreeing to surgery it is a good idea to check with your insurance company to see if they will cover all or part of the cost of the procedure. You can get more information on plastic surgery and mesothelioma on these web sites: http://www.Mesothelioma.com, or http://serg-group.org/the-general-basic-fact-you-should-know-about -plastic-surgery.php.

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Online Physician Rating and Ranking Services are Biased and Unreliable

noreply@blogger.com (Aaron Stone MD) — Wed, 15 Jun 2011 03:45:00 +0000

A study of online physician review, rating and ranking services such as Angie’s List, healthgrades.com, RateMds.com, Vitals.com, and Yelp.com by professors of the University of Maryland’s Robert H. Smith School of Business and the School of Public Health at the University of Minnesota found that they are biased and unreliable. This is particularly worrisome as physician ratings are gaining popularity among patients and an increasing number of patients consult these rankings before making an appointment to see a prospective surgeon. According to a 2010 Pew Internet and Life Project survey, 59% of U.S. adults have looked online for health information.

The study looked at the way patients determine which physicians to rate and the intensity of opinions they express using 4 data sets:

online data from RateMDs.com, one of the largest American physician rating services;
an offline patient survey conducted by the consumer advocacy group Consumers’ Checkbook for the cities of Denver, Memphis, and Kansas City;
the U.S. Census 2007 Economic Census, which was a source of information about population and median income in the three cities examined;
and state medical board websites.

They asked if patients using these online sites reviewed the full range of doctors (including those viewed positively, neutrally, and negatively); if they were biased toward giving negative reviews to doctors (which the authors characterized as “bad mouthing”); or if they were biased toward giving mostly positive reviews (providing what the authors call “sounds of silence” about poor caregivers). It turns out patients posting their opinions about doctors on online are much less likely to discuss physicians with low perceived quality and are more prone than offline populations to exaggerate their opinions,.

The authors came to two major conclusions:

First, they found that physicians with low ratings in offline surveys are less likely to be rated online, therefore supporting the “Sound of Silence” effect in selecting what physicians to rate.

Second, although authors found a strong correlation between the online ratings and offline population opinion, the association is strongest in the lowest quartile of opinions. These results suggest that online ratings are more informative when identifying low-quality physicians, but not as effective in discerning high quality physicians from median ones. The authors also confirm that patients are most likely to provide ratings for their most flagrant or negative experiences with physicians.

Doctors and professional medical societies were initially caught like deer in headlights when these online ranking and rating (but mostly raking) sites appeared. It is a premise of marketing that the few dissatisfied customers are the most vocal. That does not always mean that the product or service is inherently bad. Some irate and sometimes irrational patients without valid complaints posted highly negative reviews. These hurt the reputations of some surgeons and they lost patients, not always through any fault of their own. Complaints to these review and ranking sites went unanswered and they refused to remove negative reviews. Lawsuits against the defamers were hard to initiate because the reviewers were largely anonymous. One surgeon was somehow able to track the negative reviewer at which time it was found out that that person had never even had the surgery that was complained about. On the other side of the coin a doctor in northern California and a cosmetic group of doctors in New York were found to be posting false positive reviews. The New York group was using employees to post multiple fake positive reviews. They were cited and fined hundreds of thousands of dollars related to false advertising. The California doctor hired a public relations firm to boost the practice and the firm posted the fake positive reviews.

Next came companies that promised to remove negative reviews and track them as they appear for removal, for a price of course. Interestingly after some investigation it was noted that some of these companies were actually the source of the negative reviews and some were even the company that owned the ranking/review website. I was contacted by someone who was writing a book about these companies to expose them.

A negative review was posted about me that contained general information that could be obtained from my website but did not mention having any specific surgical procedure. This coincided in time with the first of the companies calling me to offer their paid services to remove negative reviews. A colleague of mine had a certifiably unstable patient who underwent a minor procedure, so minor that it would be hard to have a complication much less a bad result. This patient went literally into orbit posting negative reviews and even creating websites that would appear on searches for that doctor's name.

Doctors have collectively come to the conclusion that the only way to deal with this situation is to drown it out with online content like blogs and multiple websites and have happy patients post reviews. Unfortunately, happy patients in general are less motivated to post reviews no matter how happy they are. They got the result they wanted and now they want to go on with their lives. They have nothing more to gain by posting a positive review.

April 12, 2012 Addendum

Fake reviews (review spam) has become such a problem that Google commissioned University of Illinois at Chicago researchers to investigate it. They concluded the key to identifying groups working organized review fraud is their behavior. Those include multiple reviews posted within days of each other, deviation from the norm where there are already a large number of reviews, posting of similar reviews in terms of content, and the same number of reviews over multiple products. These findings do not apply to most doctors because individual doctors just do not have that many total number of reviews on the web.

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Diabetes and Cosmetic Surgery

noreply@blogger.com (Aaron Stone MD) — Mon, 30 May 2011 21:03:00 +0000

Diabetes in all its forms (diet controlled, medication controlled and insulin controlled) impacts all surgery patients. Since diabetics are more prone to coronary artery disease and blood chemistry alterations they require more extensive lab work including electrocardiograms before surgery and should be medically cleared for surgery by their internist. After surgery their healing time is prolonged, fluid balance is altered and they are more prone to infection. Therefore care after surgery including insulin doses should be performed under the guidance of the physician who medically cleared the patient for surgery accounting for the type of surgery performed and the patient's condition.

For surgery of any kind in diabetics the goal is to complete the surgery without the patient experiencing keto-acidosis, high blood sugar or low blood sugar levels. This can be reached by one of 3 approaches

no insulin-no sugar where the patient is fasted before and during surgery, takes no insulin the day of surgery and is given no intraveonus sugar

a 1/3 to 2/3 split dose of insulin and intravenous sugar given during surgery

the patient is given continuos insulin intravenously and blood sugar is monitored during surgery

For most cosmetic surgery patients who are not seriously and undergo more minor or shorter time operative procedures like rhinoplasty, blepharoplasty, breast augmentation, liposuction etc. the no insulin-no sugar approach is adequate. For longer procedures that are more involved such as belt lipectomy the split dose insulin and intravenous sugar approach are more appropriate. For seriously ill patients who may be undergoing reconstructive surgery and are not likely candidates for cosmetic surgery continuous intravenous infusion of insulin and sugar adjusted for blood sugar readings during surgery is most appropriate.

No special treatment is required for diabetics controlled by diet especially if the surgery is minor.

The care of patients whose diabetes is controlled by oral medications is more complicated. Most can be treated by the no insulin-no sugar approach taking their last dose of medication on the day before cosmetic surgery and then resuming it once they start eating after surgery. If the medication is a long acting sulfonylurea (like Glipizide) it should be stopped 3 days before surgery. If it is active in the body and the patient does not eat because of surgery the blood sugar level can become dangerously low. These patients are more likely to need blood sugar levels read right before, during and/or after surgery especially if the surgery time is longer than a few hours. They may also require a temporary switch to insulin from oral medications around the time of surgery.

I had a borderline diabetic patient whose diabetes was controlled by diet alone. The day following surgery their pancreas produced so little insulin that the blood sugar and potassium levels became alarmingly high. This was the body's response to the stress of surgery. Luckily the surgery was performed in the hospital and the patient stayed in the hospital afterward. Administering bicarbonate intravenously and insulin normalized the blood chemistry cured a potentially disastrous problem. Unabated the abnormal blood chemistry can lead to coma, seizures and even death. Lengthy cosmetic procedures should be performed in a hospital in these patients and the blood sugar levels checked periodically after surgery.

Because of all of the above if you are a diabetic and your plastic surgeon is operating on more than one patient on the day of your surgery - you must be the first case of the day. Also lengthy cosmetic procedures should be performed in a hospital setting.

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The difference between panniculectomy and abdominoplasty - tummy tuck

noreply@blogger.com (Aaron Stone MD) — Sat, 14 May 2011 07:28:00 +0000

Abdominoplasty or tummy tuck is a cosmetic procedure that involves placement of horizontal lower abdominal and around the belly button incisions. The abdominal skin is then tightened by separating the skin and fat layer from the muscle layer, pulling down the upper edge of the incision and creating a new hole for the belly button higher up on the skin that has now been stretched downward. In most cases suture tightening of the abdominal muscles is also performed. In some cases additional tightening for very loose muscle is achieved by placing additional vertical and/or horizontal rows of sutures. The result is frequently improved by liposuction peformed at the same operation. It is not a medically necessary procedure and therefore not covered by health insurance unless the excess skin and/or fat is required to close an open wound or reconstruct a breast after breast cancer surgery rather than being removed for cosmetic reasons.

Markings for Abdominoplasty - Tummy Tuck

Abdominoplasty - Tummy Tuck Surgery

Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the upper abdominal skin tightening via around the belly button and lower abdominal incisions. The hanging fold of skin and fat is called a pannus so its removal is called a panniculectomy. The skin and fat are removed as a wedge without any lifting of the surround skin - fat from the underlying muscle layer. It would be medically necessary rather than cosmetic in nature if the removed skin has had recurrent infections or rashes (known as intertrigo) or is dead etc. In such cases the panniculectomy surgery is covered by health insurance. It is called a mini-tummy tuck when the excess skin and fat is slight and does not hang over the undergarment or genitalia when standing. Like a full abdominoplasty a mini-tummy tuck is a cosmetic procedure.

Skin Removal Patterns for Panniculectomy
The pattern of removal as you can see in many cases results in removal of the belly button. Since the upper excision line is shorter than the lower excision line, especially when the skin-fat hang very low, a dart of skin has to be removed along the lower excision line in order for the 2 lines to match for closure.

Insurance coverage criteria for panniculectomy typically include:

stable weight for 6 or more months
photo documentation of skin and fat hanging over the pubic area
medical record documentation of recurrent skin rashes and/or infections in the fold of hanging skin that does not respond to 3 or more months of topical and/or oral medications

It is important to make sure you see your doctor right away if you develop these rashes or infections and have him/her document all office visits for and treatment of these skin conditions in your medical records in order to get health insurance coverage.

Although panniculectomy can be performed in morbidly obese individuals abdominoplasty should not. The act of lifting skin-fat off the underlying muscle in abdominoplasty places these patients at a very high risk of complications. For these patients it is better to lose the weight surgically or non-surgically before undergoing an abdominoplasty.

Abdominoplasty
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Breast Implants and Bodybuilding

noreply@blogger.com (Aaron Stone MD) — Mon, 02 May 2011 20:02:00 +0000

Female body builders in general have little body fat and the process can also melt away breast tissue. Refilling the breast skin envelope is then challenging in this situation because there is so too little fat or breast tissue to cover the edges of a breast implant placed on top of the muscle. So saline implants above the muscle are out of the question. Implants placed under the muscle are even more problematic because the pressures or forces applied to them during weight lifting can rupture the implant or more commonly shift them out of position. I saw one patient who while bench pressing squeezed her implant out of position so it formed an unsightly U-shape around the lower border of the pectoralis major chest muscle.

The only answer although not optimal is a cohesive gel breast implant placed on top of the chest muscle and in selective cases the addition of acellular dermal matrix to ensure the edges of the implant and rippling are not visible, although that is costly and is not be the right choice for all such patients.

Breast Implants Augmentation and a Natural Look
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