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Posted by on in Uncategorized

It is easy to be overwhelmed by the thousands of skin care advertisements on the television, radio, and magazines.  We purchase these products in hopes that we will look as good as that airbrushed computer enhanced model or actress in the ad.  What they don't tell you is the product only contains a minuet amount of the active ingredients needed to accomplish any results and the rest is just fillers.  Legally, over the counter skin care products can not penetrate past the epidermis or the outer most layer of the skin.  This works great as a lipid barrier (waterproof, protective wrap over the skin), but will not provide long term results. These products do not treat the underlying skin condition that results in the obvious signs of aging (loss of collagen) or problematic skin such as acne or hyperpigmentation.  These conditions all begin in the dermal layer (active layer) and need to be treated on a cellular level. There are many great medical grade skin care products available!  They are safer, higher quality, more efficacious, and proven to work through science. Visit your local esthetician or physician to see which products are best for you.

Posted by on in Uncategorized

PCA SKIN® offers daily care products that are dermatologist-approved and clinically researched. Each product is scientifically formulated to target and treat troublesome skin conditions at the cellular level using a progressive, NOT aggressive philosophy. With formulations free of synthetic fragrances, dyes and other known sensitizers, they consistently deliver safe, effective results without irritation.


Posted by on in Procedures
A Brief History

Chemical peels offer an excellent option for significantly reducing wrinkling and signs of Mortar and Pestleaging in the face, neck, and décolletage areas.  The concept has been around since at least the 1950's and probably earlier than that.  Specialized private formulas were developed by non-medical practitioners that were purported to decrease wrinkles.  When these were studied in the early 1960's the mechanism of action and was discovered and a whole new method of skin treatment was born.

Over the years different compounds were tried until today there is a fixed set of safe and reliable treatments.


How They Work

All chemical peels work by removing some of the outer layers of skin.  The depth of the layerspeel is determined by the chemical agent used and the concentration.  The deeper layers of the skin respond by regenerating new skin and by increasing the amount of collagen.  The result is skin that looks smoother and more youthful.


Alpha Hydroxy Acid Peels

Alpha hydroxy acids are naturally occuring acids and based on chemicals found in apples, apple_slicemilk, sugar cane, or tomatoes   In mild concentrations (10% or less) they are sold over the counter.  In higher concentrations (20% - 30%) they are usually applied by an aesthetician.  AHA's do a fine job of improving the skin's texture and can also improve fine wrinkles but they do not treat significant wrinkles.  In the lower concentrations they can be used as part of your daily skin care routine.  Higher concentrations require periodic re-treatment.


Jessner's Peels

Jessner's solution uses a mixture of an alpha hyrdoxy acid (lactic acid), a beta hydroxyJessner's Solution acid (salicylic acid) and resorcinol  mixed with 95% ethanol.  Quite the chemistry lesson here.  This peel works at the epidermal level and so will also improve the skin texture and minimize small wrinkles.  It can also be used as a pre-treatment for a TCA peel.  Recovery is rapid.



Trichloroacetic acid, or TCA, was first discovered by a French chemist, Jean-Baptist TCA chemical peelDumas in 1839.  It is prepared by mixing vinegar (acetic acid) and chlorine.  It was widely used in biochemistry but it wasn't until Dr. Zein Obagi, a dermatologist, began using it that it became the most popular peeling agent.  It works by dissolving the keratin in skin and altering the surface proteins.

It's popularity derives from the fact that it is predictable, safe, and very effective.  The depth of the peel can be controlled by adjusting the concentration.  A 20% solution of TCA works well as an epidermal peel.  Treatment can be done in the office with mild analgesics.  The erythema (redness) usually resolves quickly, often in less than a week.  Multiple treatments may be necessary.

At higher concentrations - 35% to 50% - a deeper penetration occurs.  At this concentration the the TCA penetrates to the superficial layer of the dermis.  This is considered a medium depth peel and is effective for most facial wrinkles.  Anesthesia is often recommended at these concentrations.  Concentrations more than 50% are not often used because of the risk of scarring.

Phenol / Croton Oil

Phenol has been around a long time.  It was used by Joseph Lister, one of the pioneers ofPhenol Croton oil chemical peel antiseptic surgery.  Its method of action is similar to TCA but when it was first used it seemed to always work at the same depth.  With the addition of Croton oil it was possible to control the depth of the peel based on the concentration of the oil.

Phenol peels are typically used to treat deep wrinkles, scars, and damaged skin.  The procedure requires anesthesia and takes almost two weeks before the skin is healed.  It is very effective but is not recommended for dark skinned individuals since pigmentation changes can often occur.

Posted by on in Decisions

Announcing a new sizing system!

Deciding on the correct size of breast implants used to be a very difficult process.  Now there is a great solution.  Previously, we would take measurements of your breasts, get a rough idea of what you are looking for, and then have you select from a few test implants.  The sizes were widely spaced and fine tuning was difficult.  I have had patients who, despite careful planning, have chosen to have a second surgery to change the size.  So we found an alternative.

The new MENTOR® Volume Sizing System

Mentor Sizing System

Mentor, one of the 3 breast implant manufacturer's in the US, has come up with a very clever and complete system that allows the patient to carefully select from a large variety of implants and select exactly the size that they would like.

According to Mentor:

  • The Sizing System includes a set of 18 uniquely shaped volume sizers, (nine per breast) and provide a realistic preview of the breast size.

  • Using the Sizing System, you will be able to simulate 24 different volumes, ranging from 150cc-775cc, and help your patient feel more invested in and satisfied with her size decision.

So how does this work?

The process couldn't be simpler.  You just schedule a time to use the sizing system  (that way you can be assured that you can privately use the room and system for as long as you need).  You then bring the bra that you would like to fit into, or even a selection of bras that you are interested in, and then put it on.  You can then select one of the major sizes and insert it over your breast (it is curved on the inside) and into the bra.  Once you have the rough size selected you can fine tune your selection by adding some simple add on pieces (cutely called cutlets) over the main implant sizer until you are satisfied.  And if you start off with two different sized breasts - which most women have - you can select different sizes for each side.

Sample sizers for the Mentor sizing system


I think this is a wonderful tool!

What a great idea.  You can take your time and try some different looks and decide exactly how you would like to look.  If you are curious, you can play around with larger sizes even if you have no intention of going big.  And if you are petite you can see how much different you look even with a smaller implant.  You can also get a rough idea of how much the implants will weigh and how it feels to move with a larger bust.

So indulge your curiosity.  Whether you are certain you are going to have breast implants or if you are just curious, this system is an ideal way to try out a new you!



Breast Implant Complications

Dealing with breast implant complications

It's time to talk about a subject that most surgeons would rather not have to deal with. That's the subject of complications from surgery.  Today I'm writing specifically about breast implant complications.  Surgeons do all they can to avoid complications. They never want to look a patient in the eye and say something went wrong, but complications are a fact of life.  To brush them under the rug is disingenuous.  For the surgeon to believe they never have complications is narcissistic.  To avoid mentioning for fear of scaring a patient away is deceitful.  So lets exam complications and see ways to mitigate the risk.

Complications Common to All Surgeries

These complications include simple wound infections, allergies to medications, blood clots in legs, and injuries to surrounding structures.this is the typical complications that you would see when signing a consent for surgery. They're also the complications that most people have heard of.

To begin with, there is the complication of a wound infection.  This happens in about 1% of all surgeries although the risk varies by site.  To limit the chances of infection, most surgeon give a dose of an appropriate antibiotic immediately before the incision is made.  Many surgeons may also give a dose or two after surgery, but longer periods of antibiotics actually increase your risk of infection.

Next is the risk of having an allergic reaction to one of your surgical medications.  This risk can be decreased by taking a careful history of any previous reaction you have had to medications or latex.  Then the allergies are reviewed with everyone in the operating room during a 'time-out' just before the surgery.  Of course this does not prevent against a brand new reaction and therefore anesthesia has several medicines right in their cart to treat a sudden allergic reaction.

A potentially fatal complication and fortunately a rare one is blood clots in the legs that move to the lungs - a pulmonary embolus.  The prevention of these starts again with a careful history, including a family history, of any bleeding or clotting problems.  If your surgery will last  over an hour you will be supplied with a compression device for your legs to stop the blood from pooling and keep it moving so you don't make any clots.  Depending on the type of surgery and the length, you may also be treated with blood thinners.

Complications Specific to Breast Implants

There are complications that are specific to breast implants.  Let's look at these in some detail. The most common complication is capsular contracture.  When a breast implant is placed inside of you, your body naturally creates a capsule or lining around the implant. This capsule is mostly composed of a tough material called collagen which is a major component of scar tissue.  In half of the women with breast implants this scarred capsule remains soft and supple and cannot be felt even after many years. In the other half though, there is a capsule that is thick enough to feel.  Most of the time it can just be felt and does not  cause any significant firmness in the breast or change in shape.  However, about 10% to 25 % of the time it is objectionable and  in some women the capsule can cause a great deal of firmness, leading to an obvious deformity of the breast and / or pain.  This capsule is often the most common reason for a repeat operation on the breast. In some series the rate is as high as 25% in the first year.

Although I have not had this problem personally, I think it's well worth keeping in mind when considering breast augmentation surgery.  It is also worth remembering this when you read stories about bad plastic surgery or bad results from breast implants.  They bad results are almost always caused by the formation of capsules.

Surgeons have tried a number of strategies over the years to prevent capsular contractures.  Textured implants have been tried with limited success.  Exercises have been used, also with limited success.  There is some evidence that placing the implant under the muscle will lessen the rate of capsular contracture.  This is not a hard and fast rule and some excellent surgeons I know do not follow this advice and have very good results.

Another complication that can occur is malposition of the implants.  this can lead to obvious deformity with the implants either riding too high or moving out to the sides. The nipple and areola complex can point in different directions. This type of deformity requires additional surgery.  This frequency of this complication can be limited by carefully marking the patient before surgery while in the standing position and then doing a careful dissection of the pocket for the implant.  A well designed pocket will do much to ensure that the post op position is cosmetically appealing.

Another troubling issue is asymmetry.  It is very important to realize that no person is symmetrical between both sides.  When you visit us for you first consultation I will take measurements and will point out the differences to you.  If some allowance is not made for asymmetry, then the difference you didn't notice before surgery will be quite glaring after surgery.  To paraphrase a great surgeon - if you discuss outcomes and expectations before surgery then you have an explanation.  If you discuss it after surgery, you just have an excuse.

The complication that concerns me most even though it is far less common than the others is infection at the breast implant. This can often lead to redness, swelling, and drainage.  The only treatment that is successful is to remove the infected breast implant. Then a course of antibiotics will be necessary. The implant cannot be replaced for six months. This means that you will have one implant in and one breast without an implant for half a year.  After six months a new implant can be placed. The most concerning thing about this is the excess cost. Although the supplemental insurance plan will cover removal of the infected implant it does not cover replacement of the implant six months later. Although so far I have not had any breast implant infections I would not charge a surgeons fee for replacement. There still would be a charge for the operating room and for anesthesia in addition to the charge for the new breast implant.

This list is not a complete list - just something to get you thinking about things to discuss with your surgeon.  You might want to look at my breast implant page as well as my previous blog post on breast implantation.