March 19th, 2014


There has been a dramatic proliferation of “fractionated” lasers being marketed for improvement in skin quality. Overall, they are not cost effective.

In order to understand the issues, a little biology lesson is needed.

The skin surface cells are in a layer called epidermis. These flat, layered cells are responsible for dryness, sun damage changes ( actinic keratoses) and pigment irregularity ( “age spots’ or solar lentigines).

Procedural correction of the skin surface has traditionally been accomplised by one of three methods: chemical peels, lasers, or dermabrasion. All these methods create removal of the entire epidermis, followed by reparative healing. The advantage of these methods is effective correction. The disadvantage is potential removal of all skin pigment cells ( melanocytes), leaving white, unpigmented skin.

Enter the concept of “fractionation” of lasers…The idea being to drill a grid of injury columns into the skin while leaving the tissue between columns undisturbed. The process is similar to aerating a golf green or yard. The advantage is sparing of pigment cells. The disadvantage is that only part of the skin surface is treated.

For skin problems involving abnormal pigment or sun damage the problem is uniform. Therefore, “fractionated” treatments would only partially remove the problems. Simpler, cheaper methods such as chemical peels are more practical and more effective.

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Does Experience Matter?

May 12th, 2013


The three cornerstones of expertise in plastic surgery are: talent, quality of training, and experience.

We often overlook the value of experience. Knowledge and decision-making are very important in a surgeon, but ultimately surgery is an artistic craft. As with any artistic career, the artist gets progressively better with experience. As Malcom Gladwell observed in Outliers, it takes a minimum of 10,000 hours of concentrate practice to achieve expertise. It has been true of every great musician, painter, sculptor, or plastic surgeon.

In my own case, after over 30 years of experience and thousands of surgeries performed, I am achieving the most consistent, highest quality results of my career.

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Why Do Breast Implants Get Hard?

August 29th, 2011


The body recognizes the insertion of any substance that is not a genetic match to normal tissue. The response is to wall off (isolate with a capsule) the foreign substance with scar tissue. The personality of scar is to contract to isolate and secure the foreign substance.

Of all the soft substances that can be placed to mimic breast tissue, the best tolerated is silicone. But even silicone is recognize as foreign. Within four days of insertion, the body forms a scar “capsule” around any silicone implant. Normally, the capsule remains loose, and is never noticeable. However, when scar tightens around a breast implant, it is called “capsular contracture”.

The implant does not get hard. When removed, it feels normal. On the contrary, the breast feels hard because of scar tightening around the implant. The process is not dangerous, but it compromises the naturalness of the breast.

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Breast Implants: in front or behind the muscle?

July 29th, 2011


In the upper chest there is a fan shaped muscle extending from the breast bone (sternum) to the shoulder. Anatomically, the muscle is known as the pectoralis major. Breast implants can be placed either in front of, or behind, the pectoral muscle.

Historically, implants were placed in front of the muscle. This method is still commonly employed. The advantage to placing the implant in front of the muscle ( “pre-pectoral”) is that it is less painful initially, there is no shape distortion with muscular contraction, and more central placement (“cleavage”) can be achieved. The disadvantages are that the upper edge of the implant is more obvious, and there may be a higher incidence of surrounding scar tightening.

Placement behind the muscle ( “sub-pectoral”) has been more recently popularized. Only the upper portion of the implant is actually under the muscle edge. The advantages to placement beneath the muscle are that it creates a more natural drape to the upper breast, and there may be a lower incidence of scar tightening around the implant. The disadvantage is that less central “cleavage” can be achieved, and there is slight distortion of the breast with muscle contraction.

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FDA Implant Update

June 23rd, 2011


This message forwarded from the American Society of Plastic Surgeons (ASPS):

The Food and Drug Administration (FDA) yesterday issued an updated white paper on the safety of silicone gel-filled breast implants. ASPS agrees with the FDA statement that “silicone gel-filled breast implants have a reasonable assurance of safety and effectiveness when used as labeled,” and it accepts the Agency’s position that women who receive silicone gel-filled breast implants for reconstructive or cosmetic purposes will need to monitor the devices over their lifetime. Both the FDA and ASPS agree that breast implants are not lifetime devices.  ASPS believes that the FDA white paper is informative and will be a fruitful resource for plastic surgeons – as well as for patients considering reconstructive or cosmetic breast augmentation.  ASPS shares the FDA’s view in the white paper that more than 90 percent of patients are satisfied with their outcomes from breast implantation and report an improved quality of life.  ASPS has collaborated – and will continue to collaborate – with the FDA to ensure that science forms the basis for all decision-making on breast implants, as well as all other medical devices. The Society supports post-market breast implant surveillance and ongoing data collection related to the safety and efficacy of breast implants. ASPS will continue to reiterate that patient safety is its No. 1 priority.  The FDA has provided the following links to related documents:  FDA – Breast Implants <> Update on the Safety of Silicone Gel-Filled Breast Implants (2011) – Executive Summary <> The FDA also has made available a Consumer Update <> that contains current and background information on breast implants, as well as other links to additional documents and FAQs.  ASPS has posted additional resources for members and consumers on its website at <–_IuuysfDU-wadXAootfVXhB5Gcj876yDHw==> .  The Society is determined to work collaboratively with the FDA to ensure that plastic surgery patients, consumers and ASPS members are provided the information they need to make informed decisions.

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May 3rd, 2011


Removal of unwanted body fat by liposuction is a well established procedure benefitting thousands of patients. Naturally, the thought then arose, “ Why not remove fat from unwanted areas ( hips and thighs) and replace it into wanted areas ( breast)? “

Over the past 10 years the techniques of fat transplantation have gradually been refined. The limiting factor is that that fat cells are very fragile. Removal often destroys many of the fat cells, and re-implantation yields partial, unpredictable survival. When fat cells die, they can produce small specs of calcification in the tissue.

In most areas of the body lack of survival of fat cells with microcalcification is no big deal. But in the breast, it can cause mammographic changes which look like breast cancer. If that happens, a surgical biopsy is needed.

A recent study from China, published in the April issue of Plastic and Reconstructive Surgery, reports suspicious breast calcification in 16.7 % of patients with fat graft breast augmentation. Other early reports have not shown as many calcifications, but it is too early in the experience to know the true incidence.

There is great enthusiasm for fat grafting for augmentation. It would be the perfect solution – avoiding the hassels of silicone breast implants. But as with any new procedure, it is wise to wait until sufficient experience exists to accurately assess the downside.

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April 28th, 2011


The first implants developed were gel-filled. They performed well, but some developed surrounding scar, particularly when the shell broke. In response, manufacturers developed inflatable, saline-filled implants.

In general, gel-filled implants are thought to feel slightly more natural to touch. The down-side is that they require a slightly larger incision for placement, and when the shell breaks, they have a historically higher incidence of scar formation ( “getting hard”).

Saline-filled implants avoid the concerns with silicone gel and have traditionally had a lower incidence of scar formation ( “getting hard”). The criticism of saline implants has been a slightly more “wrinkly” feel.

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April 11th, 2011


The media constantly bombards us with the latest new “filler” which will create a facelift result with a needle. Oh really?

Let’s think about that…. If you tried on a dress that was too big  one answer is to gain enough weight to fill the dress. I would doubt that you would make that choice. Obviously, the answer is to tailor out the excess material until the dress fits your underlying shape. The same is true with faces. If there is too much loose skin in a face, the answer is not to blow up the face until the skin is tight.

The second fallicy is that fillers  somehow “lift”. Fillers fill – they do not lift. When facial tissues fall with laxity, adding volume merely accentuates the drop. Clever marketing uses familiar medical terms in situations in which they do not apply. Regardless of the filler (hyaluronic acids, Sculptra, Radiesse, plasma) or the proposed biologic benefit ( collagen stimulation, growth factors, etc) there is no magic. The correction for tissue descent is repositioning. Only surgery can do that.

Injectables do have a useful role, for subtle refinement – particularly folds around the mouth and lips in small volumes. But they are only one piece of the puzzle.

With all manner of people, physicians and others, getting into the cosmetic surgery and dermatology market, it is buyer beware. The media messages claim less is more, and new is better . Less is never more; new is often unproven.

If you only have a hammer, all the world becomes a nail. When you only have a needle all the world needs injected!

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Non-surgical Skin Tightening…Really?

April 4th, 2011


The American Society for Laser Medicine & Surgery (ASLMS) just concluded its annual meeting in Grapevine, Texas. The ASLMS is the nation’s largest organization of clinicians and scientists who perform laser procedures.

Here are highlights from the meeting…

The concept of non-surgical skin tightening, particularly in the face, neck, and abdomen is always a hot topic. The principle is heating dermal layer of the skin to 55-65 degrees centigrade creating contraction of collagen.The exhibit hall was bursting with technology claiming to tighten skin. The media is excited with testimonials. Good business for doctors, but is does it really work?

Thermage TM attempts to tighten skin by using focussed radiofrequency waves to heat the dermis. The technology has been around for nearly ten years. It never really caught on because the treatments were very painful, and the benefits were limited. Solta, the company who bought Thermage, has modified the machine so that treatments are less painful. However, the results are minimal and inconsistent.

UltheraTM attempts to heat the dermis to create tightening using focussed ultrasound waves. The technology is elegant and interesting. However, the treatment parameters of depth and density, have not been established. As with many new technologies, they are marketed before the exact effective guidelines have been established. No doubt, a few patients have shown noticeable, though modest benefits – mainly in the neck. I would say Ulthera is worth watching in development, but not ready for routine use.

The problem with all this skin tightening technology is that basic studies of effect have not been completed. How much can you burn dermis without scarring? How little can you burn dermis and still get benefit? How long does initial dermal contraction last? How consistently do you get a result worth the cost?

Until these technologies have been in use long enough to either become standardized or discarded for the next “new treatment”, I would say watch and wait. There still is no minimal procedure with maximum result in skin tightening!

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Other “plastic surgeons” ?

March 28th, 2011


The American Board of Medical Specialties (ABMS) was formed in the early twentieth century to regulate the training differences between specialties in medicine and surgery for the clarification of the public. Plastic Surgery was a defined separate training pathway.

In the 1970’s other specialists decided they wanted to enter the plastic surgery arena. With a decidedly political vote of the ABMS members, other surgical subspecialists were allowed to independently develop “plastic surgery” training within their limited areas: otolaryngology, ophthalmology, dermatology.  As a result, “facial plastic surgeons”, “ophthalmic plastic surgeons”, and “dermatologic plastic surgeons” arose.

Needless to say, this approach is very confusing to the public.

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