Patients nowadays are bombarded with infomericals for exercise apparatus to tighten your stomach. Does it work? Will exercise alone flatten your stomach? Or, do you really need a tummy tuck?

The answer is . . .

It depends on the condition of your rectus abdominis muscle. Do you have a muscle separation?

The rectus abdominis muscle is the vertical muscle in the middle of your abdomen. It functions much the same as how shoe laces work in a shoe. If your rectus abdominis muscles are intact (tightened), congratulations!–you may only need exercise to firm your tummy.

However, if your rectus abdominis muscles are separated, you can only firm up your tummy with a repair of the muscle, or a tummy tuck. Since your muscle is seperated no amount of exercise can tighten that gap in the muscle. Instead, it must be stitched together.

In today’s video blog, I tell you how to examine yourself to determine if you have separated abdominis muscles, otherwise know as a rectus diastasis. Watch my video to find out if you just need more exercise or if what you really need is a tummy tuck.

Ricardo L Rodriguez, MD

www.cosmeticsurg.net

It is no secret that Michael Jackson experienced breathing problems throughout the last years of his life.  Was it a pulmonary condition, or was it something else?

I have strong reason to believe that Michael Jackson had internal valve collapse within his nasal passages. How did this happen? Multiple rhinoplasty cosmetic surgery procedures on the nose over the past 20 years removed too much cartilage and collapsed the nasal airway.

There are two types of nasal collapse that can occur and I have explained them in my video blog. These two types of collapse are:

1. saddle nose deformity
2. internal nasal valve collapse

Michael Jackson did not have a saddle nose deformity, but likely suffered with internal nasal valve collapse. This created breathing problems for the performer.

The moral of the story is that the pursuit of perfection in plastic surgery is a slippery slope. Patients and doctors need to carefully review expectations and acceptable results, because sometimes cosmetic surgery can affect function.

Ricardo L Rodriguez, MD

Dr. Conrad Murray was the physician who administed CPR on Michael Jackson. According to the web site of the American Board of Internal Medicine, http://www.abim.org:

Dr. Conrad Robert Murray- not Board Certified (expired)

Certified 8/26/98

Expired 12/31/2008

The rhinoplasty procedure is a reshaping of the nose.  In your initial consultation with your plastic surgeon you should  describe the things you want to change about your nose in specific detail.  Plastic surgeons think about the nose using certain terms and you can paint a better picture of how you want your nose to look if you use these terms in your initial consultation.

In this video blog about rhinoplasty, I explain the following terms used to describe the nose:
A. Width

• nostril (wide part at bottom)
• tip 
• dorsum (middle of nose)

B. Length

• root to tip distance (vertical length)
• projection of nose (horizontal length)

If you use these terms to explain what you want, your plastic surgeon will likely have a better understanding of what type of result you are looking for. Do not assume that your surgeon will know exactly how you want your nose to look. Noses are a very personal attribute and everybody has a different ‘ideal nose’.  You need to be specific when you describe what you want!

Hope this video helps! Let me know how you like it.

Ricardo L Rodriguez, M.D.

http://www.cosmeticsurg.net

I have previously written about the types of anesthesia used in cosmetic surgery. The various types of anesthesia include local anesthesia, various types of IV sedation where you breath on your own (twilight anesthesia) , and general anesthesia (assisted breathing with a tube).

I perform all of my major procedures, including multiple procedure makeovers with IV sedation.

The use of IV sedation offers several advantages over general anesthsia:
1- less nausea than general anesthesia
2- quicker recovery immediately following the surgery
3- eliminates the risk of pulmonary embolism which is a major concern with general anesthesia.

It is a myth that long multiple procedure cases can not be performed under IV anesthesia. I perform 8-9 hour multiple procedure cases every week. The truth is that for procedures lasting longer than 4 hours, the patient is much better off with IV anesthesia. With general anesthesia, the risk of pulmonary embolism increases with the length of the surgery.

In IV sedation, you are using your own muscles to breathe on your own. Under general anesthesia, a ventilator blows air into your lungs, altering the dynamics of blood flow throughout your body. As the duration of general anesthesia increases, so do complications related to it. This includes pulmonary complications as well as risk of blood clot to the lungs.

To illustrate how well patients can do with IV sedation, two of my patients agreed to be filmed in their immediate post operative period in the recovery room for the purpose of this blog. 

The first patient had a two hour breast procedure and you can see that she is extremely alert after just 30 minutes out of the operating room. The second patient had a multiple procedure case (tummy tuck, breast lift with implants,  and a thigh lift) which involved 9 hours of operating room time. I have filmed my patient in the recovery room just 40 minutes after she was transported from the operating room. Although she is definitely sleepy, she is remarkably alert enough to recall the facts of her procedure. She is tolerating fluids. This would NOT be the case if she had the 9 hour procedure performed under general anesthesia. I now realize that many patients I admitted to the hospital for overnight stay in the past needed to be hospitalized because of the anesthesia recovery, not because of the surgery.

Please watch the video and a big thank you to my patients for allowing me to share their experience  with you!

Ricardo L Rodriguez, MD

http://www.cosmeticsurg.net

In Episode #3 of my CosmeticSurg Video Blog I discuss the difference between two types of liposuction:
tumescent (suction) liposuction vs. laser/ ultrasonic assisted liposuction. If you are considering laser or ultrasonic liposuction you must watch this video to understand why these new technologies may not necessarily be as good as regular tumescent liposuction!

Traditional tumescent liposuction

Tumescent liposuction has been around well over a decade and allows the surgeon to have complete control of the amount of fat being taken out. The  tumescent liposuction technique is mechanical as it involves the surgeon using a long rod called a cannula to extract the fat. The motion is a continuous back and forth rhythm to remove the fat.   Since the motions are repeated over the course of 1-3 hours, your surgeon must be in good aeroebic shape to give YOU a good result!  Honestly, this is one reason why some surgeons do not use this technique!

While the basic technique used in tumescent liposuction has not changed, the size of the cannulas used to extract the fat have gotten much slimmer over the years. In the past, surgeons used larger 5mm cannulas , but  this sometimes resulted in lumpy or uneven results. Most surgeons now use 3mm or smaller cannulas.  This will increase the length of the surgery as it does take longer to remove the fat from small cannulas, but the results are well worth the longer surgical time!  The thinner 3mm cannulas produce excellent and consistent liposuction results. With thin cannulas, traditional tumescent liposuction can achieve the smoothest and most even result possible . 

Laser and ultrasonic liposuction

The new technologies for liposuction technique  include laser liposuction and ultrasonic liposuction. They emit high energy that liquefies and destroys tissue around the cannula. I do not think these technologies are worth the risks they pose to the patient. Both of these techniques essentially melt the fat under your skin. As they melt the fat, other tissues are damaged. I am not a fan of damaging tissue or fat cells that are not being extracted.  Often times, the extracted fat could be used for fat injections to rejuvenate another area of the patient’s body.  These technologies destroy that possibility. Additionally, these high energy ultrasound and laser technologies can have complications such as burning, and results can be very unpredictable as it is impossible to tell how much damaged tissue is left behind.

Best technique is tumescent liposuction with slender cannulas

In summary, the best technique available for liposuction is the  traditional tumescent liposuction technique with small diameter cannulas. It has stood the test of time. Sometimes the latest is not the greatest. I perform hundreds of liposuction procedures each year and I do not remember the last time a patient asked for a touch up for lumpiness or unevenness. Thin cannulas give you the best chance to get the result right each and every time!

Ricardo L Rodriguez, MD
http://www.cosmeticsurg.net

I filmed my second Video Journal when I brought my son up to Yale University in New Haven last weekend. Rico is a rising senior at Yale University and every time I visit the campus, it brings back great memories of my Plastic Surgery training at Yale. Rico was actually born at Yale New Haven Hospital during my residency program.

I have trained at a number of great institutions including Tulane, Charity Hospital in New Orleans, University of Wisconsin, Royal Marsden Hospital in London, NYU, and Yale University. The Yale Plastic Surgery Program was unique in that they taught via the Socratic Method instead of the Great Master’s Method used by other teaching programs.

In the Socratic Method you arrive at knowledge through a process of questioning and answering. The exchange stimulates logical thinking and illuminates ideas. In the Great Master’s method, students learn the techniques developed by the great masters. I feel that the Socratic Method is better suited for the field of Plastic Surgery, as every patient situation requires a unique solution . Techniques learned from the great masters may not be the best solutions in certain individual cases.

During my Plastic Surgery residency in the mid-eighties, my Chairman, Dr Steven Ariyan once said ” Twenty years out of training you won’t be doing anything like you learned it here “. As I celebrate my 20th year in practice, I reflect on how grateful I am for having trained at Yale!

Ricardo L Rodriguez, M.D.
http://www.cosmeticsurg.net

There is no doubt that the most exciting frontier in medicine now is the use of stem cells. Stem cells have the power to restore beauty, heal damaged tissues, and the potential to treat and cure some diseases.

Embryonic stem cells vs. fat stem cells

Up until recently the media has largely focused on the more controversial embryonic stem cells. These are stem cells derived from embryos. The potential uses of these cells to cure and treat diseases remain vast, but the controversial source of the cells poses ethical questions which have delayed medical progress.

During the past decade, researchers have discovered that stem cells can also be extracted from your own fat tissue. These adult stem cells have the same potential as embryonic stem cells, except for the ability to differentiate into sperm or ova. Unlike embryonal stem cells, stem cells extracted from your own fat are abundant, easily available, and pose no ethical or political controversy.

Cosmetic enhancements vs. therapies to treat diseases

Due to FDA regulations, stem cell therapies to treat diseases are not yet available in the U.S. unless you are part of a clinical trial. In this capacity they are considered to be ‘drug therapy’ and subject to very strict regulation. Therefore, patients not enrolled in these trials are currently traveling outside of the United States to get these therapies.

But using your own (autologous) stem cells to restore a more youthful appearance is available now, from experienced plastic surgeons here is the U.S. There is no need to travel to China, Korea, or Europe to get stem cell enhanced facial rejuvenation or breast augmentation. These therapies do not fall under the FDA’s ‘drug therapy’ classification and are therefore not regulated as such because: 1) the injections are performed in the same operative session as the liposuction procedure to remove the fat; 2) the stem cells have been only minimally manipulated; and 3) the stem cell enhanced fat transfer does not alter the original relevant biologic function of the stem cell. Thus, when the cosmetic enhancement is performed in the same operative session, it is not regulated by ‘drug therapy’ guidelines.

However, if your autologous stem cells are reinjected in a separate or second operative session, it is unclear whether the FDA considers that application to be a drug therapy, even though it is used for the same cosmetic purpose. There is currently an intense legal debate about what constitutes ‘drug therapy.’

Plastic surgeons and fat grafting (fat injections)

Plastic Surgeons have been extracting and reinjecting fat cells into tissues for over a decade. Experienced fat grafting surgeons have known that successful fat grafting is highly dependent on the techniques used for extracting, processing, and reinjection of the fat cells. Surgeons are beginning to understand that fat processing techniques which result in high concentrations of adult stem cells produce not only long lasting results, but also have therapeutic results in injured tissues.

Stem cell enhanced fat injections

To perform stem cell enhanced fat grafting, fat is first extracted by liposuction using low negative pressure. The fat is then processed. Proper fat processing techniques include centrifugation and decanting of the extracted fat. Long lasting results are only achieved with proper fat processing techniques.

In contrast, surgeons who rinse the tissue decrease stem cell adherence to fat cells, and do not increase the concentration of stem cells. These less concentrated grafts have a smaller percentage of success.

Reinjection of the fat must be performed in very small quantities and distributed through all tissue layers to facilitate reestablishment of blood flow to the fat grafts.

Areas which benefit from stem cell enhanced fat injections

Examples of stem cell enhanced fat transfers which can be performed in the same operative session by plastic surgeons at the present time include:

1. Facial fat injections - The fat transfer to the face is not just a volume filler. The stem cell enhanced fat can actually rejuvenate your facial tissues and skin. Stem cells assist in increasing blood supply to tissues to make tissues look younger.
2. Breast Augmentation- Fat injections provide a natural alternative to breast implants
3. Brazilian Butt Lift- Originally used for buttock enhancement, stem cell enhanced fat transfers are being used in body contouring to create an hourglass figure.
4. Hand Rejuvenation- As in the face, there is not only a volume enhancement, but aged hand skin is revitalized by the fat transfer.

Other areas of stem cell therapy which are being investigated and currently developed are:

1. radiotherapy injuries
2. tissue defects
3. lumpectomy reconstruction
4. breast reconstruction after cancer

Stem cells are the new frontier in plastic surgery

Stem cell therapy is a paradigm shift in cosmetic surgery. Instead of the surgeon using his talents to create the illusion of a more youthful body, the surgeon guides your body to rejuvenate itself!!

Ricardo L Rodriguez, MD
Board Certified Plastic Surgeon
http://www.cosmeticsurg.net

This is my first attempt at a video journal.  Please send me ideas of plastic surgery topics you would like explained! What would you like to know or see? 

The topic of Episode 1 in my CosmeticSurg Video Journal is liposuction cannulas.  In the liposuction procedure, the cannula is the long slender rod which is used to extract  fat from unwanted area.  I will explore the evolution of the liposuction cannula and discuss why cannula size is important to get a good liposuction result.

If you have a question about anything I say in the video, please ask! Remember that if you have a question, probably many people are also having the same question. So, by submitting questions on this blog you are helping me, because I can’t always guess what patients want to know. By asking and getting an answer to your question, you are helping many others by educating them.

Go ahead, ask me a question!

Ricardo L Rodriguez, MD

A recent question to the blog:

“What is iv sedation and what is the difference between that and general sedation? Is the patient out completely and will not feel anything? I am interested in Breast augmentation but have a lot of questions.”

Anesthesia monitor

In cosmetic surgery, we often refer to the three distinct choices: local,  IV or General Anesthesia. However, I have outlined all of the slight variations so you can fully understand the entire spectrum of anesthesia. In general, my bias is to use as minimal sedation as possible, but ensure that the patient  does not feel or remember anything. Following are examples of increasing levels of anesthesia and examples of cases that might be suitable.

1- Local anesthesia only- 

This is suitable for small lumps and bumps. I have used it for small wound revisions, but you have to know very well what your level of pain tolerance or anxiety is. I am a poor judge of it myself, and once I underwent a gastroscopy under local. Wow, all I can say is I will never do that again! If you are anxious about needle sticks, you might consider going up to the next level.

2-Minimal sedation-

This usually means giving the patient some Valium or other anxiolytic agent in combination with pain medication such as Percocet by mouth. This is done a good half hour before surgery. The patient should be visibly relaxed or sleepy. In combination with a good local anesthetic, we can do eyelifts, liposuction of small areas, lip lifts, fat injections to the face, and scar revisions. Some patients bring their Ipods with them, or we supply them with ipods from our office. The combination of earphones, sedation and good local anesthesia can do some amazing things. I once did a mini tummy tuck under minimal sedation.

3-IV Sedation- Minimal-

If I decide to use IV anesthesia, I  perform it with an anesthesiologist on board. He is responsible for monitoring the patient’s vital signs so I can concentrate on surgery. Minimal IV sedation is really just a step up from Minimal sedation with oral medications as discussed in option 2, except that with the IV and anesthesiologist on board I can ramp up to any level of anesthesia I need. This is great for a patient who does not know if she/he will tolerate only local anesthetics and wants to make sure she/ will be comfortable. I have done eyelifts, revision nose jobs, and fat injections to the face with this technique.  It is perfect for lip lifts, where the patient is too anxious to have it done under local anesthesia, but I want her to be really coherent  and able to see if she likes the level of lip lift.

4-IV sedation Moderate, also known as Twilight anesthesia or Conscious sedation.

This level of anesthesia includes amnesic drugs, which make the patient forget what happened during surgery. The patient is usually asleep, but able to breathe on his/her own. If the patient feels some pain they may moan and verbalize, or even move some. We generally will then administer more local anesthesia which will be adequate for the level of surgery we are doing. Sometimes patients may need small adjustments in head position to help them breathe better. Upon emerging from sedation patients do not remember what went on and sometimes will even ask if surgery was done. This type of sedation is great for  facelifts, capsulectomies, breast reductions, mini tummy tucks, and facial implants.

5-IV Sedation- Deep sedation

With deep sedation the patients are able to breathe on their own but need an assistive device such as a nasal airway or oral airway. We can do any kind of major plastic surgery including body lifts, combined procedures, etc., provided we use good local anesthesia. Tumescent anesthesia has been great for us in these cases. The beauty of this technique is that since the tumescent local anesthetic agents we use are long lasting, the patient can start emerging from the intravenous anesthesia well before the end of the case. It is  rare that a patient will ever feel pain or remember anything during deep sedation.

6-Total Intravenous Analgesia, also known as TIVA or General sedation, or General Anesthesia

These patients need respiratory support. We at Cosmeticsurg do not believe it is necessary to use TIVA, as we can achieve all our goals with lesser amounts of anesthesia. 

Most patients are concerned about the possibility of feeling something during surgery, and so they tell me they want to be totally out during surgery. Before becoming proficient with IV sedation, the way to achieve that was with an inhalation general anesthetic. The problems of general anesthetic are well known: nausea, prolonged recovery times, sometimes needing to admit the patient overnight, and increasing risk of the anesthetic itself with increasing time of surgery. The problems of nausea and prolonged recovery are eliminated with IV sedation. More importantly, there is no increased risk with increased time of surgery.

I feel very strongly that monitored IV sedation is the way to go not only because of the increase in patient comfort, but more importantly, because it is safer.

Ricardo L Rodriguez, MD

http://www.cosmeticsurg.net