Let’s Talk About Breast Implant Complications

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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.

 

Deciding on Cosmetic Breast Augmentation

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All About Breast Augmentation

Before getting into the specifics of breast augmentation, make sure you take a moment and think about why you want an augmentation.  Each woman has a different reason for considering a breast augmentation.  For some, the person that stares back at them in the mirror is not who they are. Other women want to feel more dramatic. They enjoy being noticed.  Some women feel that larger breasts make them more attractive.  Sometimes there is a desire to get back what was lost after pregnancy.   There are as many different reasons as women.  I feel that the only wrong reasons are to fix relationships. Don’t think a breast implant will fix a bad relationship or to improve an abusive one.  Making a decision for implant surgery is serious, but I want it to lead to a joyous outcome.  Think carefully.

 How to Decide on Size?

Size is usually your first decision.   Are you looking for a subtle change in your silhouette?  A change to your décolletage?  Or do you want to turn every head in the room?  In order to show you what sizes are possible and reasonable, I will make some measurements of your breasts.  Every breast has a ‘footprint’ on the chest wall.  As long as the implant fits well within this natural footprint, the implant will look more natural – without the fake look.  Expanding beyond this natural foot print looks very unnatural.

The most important measurement is the breast width.  This measurement determines the base width of the implant and is the first step in selecting the appropriate implant.  The next item to determine is how much projection should the implant have?  That depends on how much volume you wish to achieve.

 Deciding on the volume can be done a number of ways, but I have found that the easiest is to have you select a bra with the cup size that you desire. Then you come to the office and try on your bra with different trial sizers placed in the cup. Once the volume is chosen, an implant with the desired volume that matches the base diameter is chosen. Trust me, it is easier than it sounds!

What Type of Implant is Best?

Implants have developed significantly since the first silicone gel breast implants of the 1960′s. Manufacturing techniques are now on the 5th generation. Elastomer coated shells and cohesive gels have all but eliminated rupture and gel leakage. The FDA has again affirmed the safety of the silicone gel implants.

The alternative to silicone is the saline filled breast implant. This implant uses a silicone shell also, but instead of being filled with a cohesive gel, it is filled with sterile saline.

Silicone Gel Implant

Which is better?  I would have to say the silicone. About 90% of women choose silicone gel breast implants. Saline does have one advantage. If the implant ruptures the saline leaks out and the breast deflates. Quickly.  There is no doubt if something happens to the implant. But silicone has these advantages:

  • The implants feel much more natural. They are soft and feel very much like a normal breast.
  • Longer lasting. The implants typically last much longer. In fact the very first silicone implant was doing fine 47 years after placement.
  • Both of the major manufacturers offer a generous warranty for defects in gel implants.

Implant Position

Implant Position

There are two possible placement positions for the implants.  One option is to place the implant between the natural breast tissue and the underlying muscle.  The second option is to gently place the implant under the chest wall muscles. The implant will do fine if it is on top of the muscle and between the muscle and the natural breast as long as there is a reasonable amount of breast tissue.  The natural breast will cover the implant and make it difficult to feel.  This is the preferred placement as there is a little less pain right after surgery.

If there is not much natural breast tissue then the implant will do better under the muscle. The elevate muscle softens the edge of the implant and makes the breast look more natural. Since the muscle has been disturbed however, there will be a little more pain after surgery. This extra discomfort resolves very quickly.

Location of the Incision

Possible incision choices for implant placement

There are three common incision sites used in the placement of the implant. Each of course has its it own advantages and disadvantages. The most common site to place the implant is under the breast in the inframammary location. The reason it’s the most popular is that this location allows the best view of the pocket that is created for the implant. It will allow for any adjustments of the fold beneath the breast. Also, if any additional surgery has to be done at a later time, this is the incision that will be used. Choosing a different incision first means that you may eventually end up with two incisions on the breast. The only disadvantage is that this scar will be visible when you are not wearing a top. Fortunately it does not typically form a serious scar.

The next most common incision is around the areola. The advantage here is that the incision is hidden a bit better, although still visible when going topless. The incision typically fades well, but can be seen on close inspection. The main problems with this location is the difficulty in doing revisions if needed.

Lastly we come to the axillary incision. The obvious advantage here is that there is no incision on the breast. The pocket is created from the armpit down. Placement of the implant is done under the muscle from this approach. The biggest disadvantage occurs in people who make prominent scars. The scar is easily seen when lifting your arm or sunbathing.

Getting Ready For Surgery

Post op binder

Support bra

After the initial office consultation and the followup, there are a few things to consider. You should plan on being off from work for about a week although some patients return in 2 – 3 days. If your job involves any lifting then you will need to arrange for light work or more time off. Typically it takes about 3 weeks until it is safe to lift heavy things and do aerobic exercises.  The lifting restriction also applies around the house too.  This is a great time for your husband or boyfriend to step up!.  If you have neither, then arrange for friends to help you out.  Someone should stay with you for a couple of days.

Let’s discuss what type of post operative garment you will need. Typically a comfortable binder will be selected although a soft sports bra will work well.  You can also purchase one of the specific post op bras.  In some cases I will ask you to purchase an underwire bra.  These are not usually worn in the immediate post op period but occasionally, when the inframammary fold is moved, the extra force is needed to help shape the fold.

The last step is to review all of the medications you take.  Make sure to discuss all medications with me.  Include all of the herbal supplements or over the counter medications too. The reason is that some medications will inhibit blood clotting or healing. I want to do our best to limit any complications and excessive bleeding can cause a hematoma. The medications to avoid include:

  • Aspirin or any medication containing aspirin
  • Any medication containing ibuprofen
  • Tricyclic antidepressants
  • Herbal supplements including Gingko Biloba, Fish oils, and St. Johns Wort

The complete list of medications to be avoided can be found here. Please review it carefully and discuss anything on the list with me or my office.

 The Day of Surgery

Your surgery will involve a general anesthetic. Although some practices will try to do breast augmentation with some sedation and local anesthesia, I feel that is much too traumatic. I want you to feel comfortable and have minimal pain, so a general anesthetic is preferred.

Since you are going to sleep you will have to avoid eating after midnight before your surgery. By having an empty stomach you will minimize the risks of aspiration while you sleep.  While you are sleeping we will use compression devices on your legs to keep the blood flowing and minimize any chance of clots.

Your surgery will last about 1½ hours. You will then spend around an hour in the recovery area. You can be sent home when you can walk to the bathroom, drink some juice, and eat some crackers without difficulty. Your will get prescriptions for pain medication and a very short course of antibiotics. You will also get some pills in case you have nausea. You will find  a simple dressing over the incisions and a wide temporary ace bandage. Make sure you have a ride home – you can’t drive on the day of surgery.

Post Op Care and Expectations

The most important thing to remember after surgery is that I want you to call for any problems. I will stress that over and over again. I don’t expect you to know what is normal and what isn’t, so anytime a question or a concern comes up, call me. I will never fuss at any patient no matter how many times they call. If you call after hours you will be directed to call me on my mobile phone.

The day after surgery you may remove the ace wrap and any gauze. You will see a small tape over the incision. Leave that alone.  The tape will fall off on its own in one or two weeks.  You may shower but just pat the dressing dry – no buffing. Do not get the wound wet in bath water.

There are some exercises that I want you to do after surgery.  On the first few days you will be sore and all I ask is that you lift your arms straight up over your head a few times per day.  If this is painful then just do what you can.  After a few days you should not have trouble lifting your arms.  When the initial discomfort settles down I will have you do some gentle pushing on the implant in all four directions – up, down, left, and right.  Don’t worry, I will review this with you before surgery and go over it again at your first post op visit.

Risks and Complications

There are definitely risks with having a breasts augmentation.  Some are related to the general risks of surgery, others are specific to breast implants.  Since I am getting a bit long winded, I think it best to leave this lengthy topic to a post all on its own.  So that will be my next post / article – Risks and Complications of Breast Augmentation.  See you soon.

To discuss breast implants or to schedule your free consultation, go to my breast implant page for more details.

Surgical Cure for Migraines

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To say that surgery can cure migraines is a bold statement.  Recent studies from Case Western Reserve University, Georgetown University, and the University of Texas Southwestern Medical Center have pointed out a mechanical reason for migraines and have shown that surgery can indeed provide a cure for the majority of migraine patients.  I want to take a few moments of your time and discuss the evolution and rational for these treatments.

Lets look at the progression of migraine treatment, starting with the discovery of Botox® as a treatment.  Botox was originally used by ophthalmologists to treat blepharospasm (a problem with the eye muscles).  A husband and wife team (ophthalmologist and dermatologist) found that Botox decreased frown lines in the forehead.  That was the start of cosmetic Botox use.  What several plastic surgeons noted was that patients treated with Botox who also happened to suffer from migraine reported a significant decrease in the frequency and duration of their headaches.  Neurologists made note of this benefit and began studying Botox as a treatment.  After several studies, Botox was approved by the FDA as treatment for migraines.

Shortly after this it was noted by some plastic surgeons that patients reported relief of their migraines following forehead rejuvenation, either by open or endoscopic brow lift. This lead to several studies showing four common trigger sites for migraines:

  • Where the nerve that gives feeling to the central forhead passes through the scowling muscles above the eyebrows
  • Where the sensory nerve to the temples and side of the forehead / scalp passes over the temples and the chewing muscles underneath
  • At the back of the head where the sensory nerves pass through the muscles that hold your head straight and help you look up
  • From problems within the nose – such as a deviated septum or other deformity on the inside.

The benefit of migraine surgery was still questioned, so a remarkable study was designed.  A group of about 70 people agreed to have surgery with 20 of them randomly selected to have a sham operation.  That means that they had the anesthesia and the incision, but then nothing was done to the nerves.  Only the surgeon and the operating team knew who had the real surgery.  Things were kept simple so only a single nerve compression site was released.  After a period of recovery, a different doctor examined the patients and asked them about their symptoms.  He had no idea who had the real surgery and who had a sham operation since they all had the same incision.

The results were remarkable.  A majority had no further migraines and most of the remainder had a significant decrease in the number and severity of headache.  The examiner did not know which patients had the sham procedure and yet was able to tell who was real with certainty most of the time.  Since then the surgery has been improved to include all 4 sites.  Now the complete relief group is higher than 80%.

Studies are ongoing now to help figure out why there are still some non-responders.  It seems likely that two other causes may explain the persistent pain and both are due to the nerves wrapping around local arteries.  The temporal artery can wrap around the nerve to the temple region giving an intense pulsing migraine.  The same can happen in the back of the head with the occipital artery.  Treatment of these conditions may improve the surgery even further.

So how does this work?  You might be referred to the plastic surgeon by your neurologist, your internist, or you can refer yourself.  The plastic surgeon will probably send you a headache log where you fill out details for at least one months worth of migraines.  This log will help determine what type of migraines you have and where the likely sites of nerve compression and irritation are located.  You may also be asked to get a CT scan of your sinuses to see if you have any nasal problems that can cause your migraines or add to the symptoms of other trigger points.  You will likely be asked to fill out an additional questionnaire to supply more information about your headaches.

The next step is often a trial of Botox injections.  The purpose is to confirm the trigger(s) for the migraines and help confirm the surgical plan.  Relief typically occurs within 1 to 2 weeks.  Any residual symptoms are noted.

Next a surgical plan is formulated and discussed with the patient.  The surgery typically takes about 2 – 2 1/2 hours, depending on the number of trigger sites.  Complications are minimal and return to work usually takes about 1 week – slightly longer if nasal surgery was required.

Is migraine surgery for you?  Although the criteria are not written in stone, I think that you should consider surgery if you have migraine symptoms more than 14 days out of every 28 and if you do not have a good result from standard medical treatments.  I also think you should consider the surgery if your migraines affect your ability to work or affects your normal social relationships.

For more information you can ask questions about migraine surgery on my website or contact my office at 770 682-3375 to schedule an appointment.

Four Important Words

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Board certified plastic surgeon.  Those are the words you must see if contemplating any cosmetic surgery procedure.  You might ask yourself “Does that really matter?”.  The answer is an emphatic yes.

The number of reports about ‘botched’ plastic surgery has skyrocketed recently.  A careful inspection shows that most of these so awful results where not performed by real plastic surgeons.  Most of the surgeries reported in the media are performed by licensed physicians, but not board certified plastic surgeons.  What’s the difference?

To become a board certified requires completing an approved medical school.  Then there are a few options.  Older plastic surgeons used to complete a 5 year general surgery residency followed by 2 years of plastic residency and sometimes an additional fellowship.  (That was my path.)  Another options is to complete a combined program with 3 years of general surgery and 3 years of plastic surgery.  An additional path is to complete an ENT, Orthopedic, or oral surgery residency and then complete plastic surgery.

You can see that whatever path is chosen, the training is extensive.  General patient care is learned first, then the fine points of cosmetic and reconstructive care.  It is an extensive training program.

Lets look at some of the recent news posts about botched plastic surgery:

Each of these news articles are worth reviewing.  They are scary and the should give you pause.  Is your surgeon certified?  In plastic surgery?

One more thing I want you to see.  Watch this very short video, put out by the ASPS.  The video is on the main page and is entitled “Do Your Homework“.

So please, do your homework.  Make sure your surgeon is board certified in plastic surgery.  Make sure your surgeon is a member of the American Society of Plastic Surgeons, so you know they adhere to ethical principles and lifetime learning goals.  Make sure not to skip this step or you could end up on one of the ‘awful plastic surgery’ websites.  I’m sure that is not the way you want people to see you.

 

 

Hands down

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Some of the odd stories from the plastic surgery world.

I enjoy doing cosmetic surgery.  A lot. But when I came out of my residency all fresh and eager and thinking the world would beat a path to my clinic, a little dose of reality hit me. And so, along my journey to becoming a cosmetic surgeon, I did a little hand surgery. No, I did a lot of hand surgery.

Hand surgery is an odd sort of specialty. On the one hand – it takes a lot of expertise and a lot of practice. It combines delicate microsurgery, refined orthopedic surgery, plastic surgery skills for skin and soft tissue coverage, and a team approach involving a dedicated hand therapist. On the other hand – most of the patients are dumb as bricks.

You might think that most of the major hand surgery trauma is just from simple accidents. You would think wrong. A simple accident, such as shutting a finger in the door, an accidental slip of a knife, a simple broken finger, or a sprain rarely requires a hand surgeon.  An ER doctor can handily dispose of those issues.  No, a real major injury requires intense effort.

Lets look at a few examples. First we have ‘The Hunter‘. As you might expect, ‘The Hunter‘ likes to hunt. He especially loves to hunt ‘old school’ with a musket, a round ball for a bullet, and an old style powder horn filled with black powder.

Now ‘The Hunter‘ also likes to drink. And to make this a truly southern redneck kind of story, he likes to smoke. Can you see where I’m going here? One evening, after a dinner of hops, malt, and barley washed down with a few beers, he sets his black powder horn down. In his ashtray. On top of a lighted cigarette. It dawns on him that this might not be a safe practice. He picks up the now smoking black powder horn and bang. Blew his right hand clean off at the wrist. There really wasn’t much for me to do other than make it a little shorter and close everything up. He had to go home the next day and clean his right hand off the walls of the trailer with his left hand.

Sometimes, fashion can cause a major hand injury. Case in point, the ‘Hip Hop Wannabee‘. This guy loved the gangsta look. Lots of chains, tatted up arms, and droopey pants. He felt like he fit right in with his thug look. Until he met a couple of real thugs. After they messed with him for a while he tried to run off. Of course his pants were hanging somewhere between his hips and his knees. So he had to reach back and hold them up while he tried to run. He looked so comical one of the thugs thought it would be funny to shoot him in the ass. Which they did – right through his hand and into a butt cheek. It really was hard to keep a straight face while he explained how this happened.

I often ask how an injury occurred. I don’t know why since so many people with hand injuries lie. Case in point was the police officer who came in at 2:00 AM in street clothes. He had a bullet hole clear through the middle of his hand. He also smelled a little of alcohol. When asked what happened he stated that he was reviewing gun safety with his neighbor while they were have a discussion over the fence in the back yard. He said he was explaining how important it was to keep your hand off of the slide where the spent shell ejects from since it can cause injury. He never was able to explain how this caused a bullet hole. Not only that, a very big bullet hole – bigger than a 9mm pistol would make. And with no gun powder around it, the hole was not made at close range. Go figure.

About 15 years ago I got a call to the ER for some missing fingers. Seems a former bikini model was getting up in years and felt that she was no longer getting modeling jobs.  She became very depressed.  Alcohol always helped her feel better so she took up alcoholism as a hobby. One night when she was driving home she had trouble holding the steering wheel of her car. She looked down and much to her surprise found that her fingers were missing on her left hand. At least that’s how the 911 call came in. The police officer that was dispatched found her at the side of the road, very distraught and very drunk. He also noted that her car bad been in a bad wreck which she had not noticed. It seems she was driving drunk, rolled her car a few times, and in the process her left hand flew out the broken window and the fingers were amputated. She never noticed until her car flipped upright and she tried to grab the steering wheel.

I think that is enough stories for now.  I have more, but I’ll save those for a later post.  As you might expect, the details have been changed a bit to protect privacy.  And since this is posted on my cosmetic surgery blog, be sure to visit my website for cosmetic surgery information.  Thanks!

 

 

The Joys of Tummy Tucks

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I do a lot of tummy tucks. And the patients are generally happy.  It’s not a perfect procedure and there are some real risks, but I find that when someone has lived with a lot of extra sagging abdominal skin along with bit of a bulge they are excited when they can get their feminine curves back.  And a tummy tuck often makes a dramatic improvement.

Let’s talk about what a tummy tuck will and won’t do.  First, it’s not a a weight reduction technique.  Although I have removed up to 10 lbs of abdominal pannus (folded skin), weight removal is not reliable.  Second, a tummy tuck won’t remove significant ‘love handles’.  The surgery ends when you reach a patient’s sides.  By adding liposuction to the procedure you can decrease the rolls on the side,   But unless you plan on doing a ‘belt lipectomy’, which is a much larger surgery, you have to stop at the sides.  (A belt lipectomy includes the tummy tuck, a lateral thigh lift, gluteal lift, and back lift).  Lastly, the tummy tuck does not do a good job of thinning out the upper abdomen.  Liposuction can help in this area.

Where a tummy tuck (abdominoplasty) shines is in removing the rolls in the lower abdomen and in rejuvenating a more feminine curve to the abdomen and upper hips. (Assuming your a woman.  If you are a man, then the goal is a firmer, flat abdomen.)  The concept is straightforward.  Depending on how much skin needs to be removed, the incision is started above the belly button (umbilicus) for a large roll and under the belly button for a little bulging.  The extra skin is removed.  Before closing the incision, the abdominal muscles – rectus muscles – are usually sutured back together in the midline.  These muscles move apart during pregnancy or weight gain.  By bringing them back together the bulging in the abdomen decreases and the waist is more defined.  Some liposuction is added here to define the love handles and upper abdomen if necessary.  Then everything is closed up.  Other than a little trouble standing up straight for a few days, most people do just fine.

There are a few possible complications though – like with any surgery.  Smoking makes these much more likely.  Infections can happen, although are rare.  Wounds can heal more slowly then you would like.  It is even possible to lose your belly button, although this is fortunately very rare.  If you are planning on a tummy tuck make sure your physician goes through all of the risks so you can decide if this procedure is for you.

And there you have a nice summary.  If you have any questions, please feel free to post a comment here or visit my website to ask for information.

 

Growing a blog

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Its been a few weeks since I started writing this blog.  I have all of these topics in my head, so I have plenty to write about.  But – I would like to make sure that other’s are aware of my work.  I searched Google for information about blog directories and getting my blog listed.

The technorati site seemed very professional.  I joined and added my blog.  To protect themselves from random people adding blogs they gave me a special code to add to a post.  They will then scan for this code:  8FEJKUD4NQRR.  When they find it, I can be added.

I also found a few other directories and submitted to them.  So – hopefully you will see this blog showing up in searches.  One, LS Blogs asked for a link, so: LS Blogs

Be well!.

A Primer in Skin Care

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I knew next to nothing about skin care. I know, I’m a plastic surgeon.  I should have had a lot of exposure to skin treatments.  But besides some simple customary bits of knowledge (like Retin A is good), I’m just a guy.  This stuff baffles me.  So it was time to really do some reading.

I have spend the last couple of weeks reading both the plastic surgery literature as well as a ton of maketing material about skin care and skin treatments.  Wow.  So let me divulge a few things I learned.  First, I have to give a few definitions since these have always thrown me:

  • Solution:  A solution is thin and watery.  It is usually made up of water or alcohol.  One example would be Betadine solution – used to sterilize the skin for surgery.  Another good example  would be the deep cleaning astringent’s used for nightly skin cleansing.
  • Lotion: A mixture of oil with a solution.  They are thicker and have a softening effect on the skin.  If there is too much alcohol they can be drying.
  • Cream: A cream is a mixture of oil and water in nearly equal proportions.  It is thicker than a lotion.  It absorbs well into the outer layer of the skin.
  • Gel: A gel is thicker than a solution and is usually an emulsion of a semi-solid in an alcohol base.  Tends to be drying.  Easy to mix with fragrances.
  • Ointment: An ointment has a higher oil component – usually 80% oil to 20% water.  They are very moisturizing.  Think Vaseline.

 

Mortar and Pestle

 

Armed with a little knowledge, I reviewed many of the available product lines.  Obagi, M.D. Forte, Neutrogena, L’Oreal, and others whose names all run together.  I have to say I really like the Obagi system.  They have a number of different product groupings depending on the area treated and the goal.  Let’s focus on their Nu-Derm System.  I was so impressed I actually got the full set for my wife.  (Not that she needed any skin care.)  She really likes the system too.

The Obagi Nu-Derm system has multiple components or steps.  The first is Prepare.  This step offers the option of a foaming gel based cleanser (remember gel is more drying so it is better for oily skin).  There is also a more gentle cleanser for dryer skin.  Both of these are followed up by a toner to adjust the pH of skin to allow better penetration of the next steps.

Following preparation is the Improve step.  There are a couple of choices here.  One is a mild bleaching agent containing 4% hydroquinone.  This serves to reduce hyperpigmentation and even the skin tones.  Following this is a choice of two exfoliants.  An exfoliant removes old skin cells and promotes new skin formation to give a healthier complexion.  The first choice is a mild 3% plant acid and the second is a stronger alpha hydroxy acid preparation.

Next is an optional Stimulate step.  The reason I describe this as optional is that the ingredients are similar to the previous step – skin tone smoothers and non prescription skin brighteners.

Of course, since you have invested all of this effort, you need the Protect step.  This includes a choice of sun block as well as a SunFader to remove blotches and smooth the skin tones.

There are also complimentary products that can be used around the eyes and to moisturize dry flaky skin.  And lastly is the option of adding tretinoin (Retin A) which is both a fine acne treatment as well as an excellant treatment for fine wrinkles.

I’m getting long winded so I will leave this discussion for now.  Post if you have any questions and I would be happy to answer them – even if it takes a little research on my part!  And don’t forget to check out the page on my website involving fillers, botox, laser, chemical peels.

Perfect skin

 

You can check out Obagi at this address.

 

A New Website. How hard could it be?

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I created my first website a few years ago.  I’m not sure why I thought it important.  I was doing mostly reconstructive surgery and my patients were finding me through insurance referrals.  Still, I thought it worthwhile.   I download some free tools and created a vary amateurish website.  Fortunately, no one visited it – so I never had to hear ridicule.

Then I started to do more and more cosmetic surgery.  A web site is important for patient information and marketing.  I didn’t want to overpay for a commercial site – so I used a copy of Adobe’s creative suite and made a better site.  Still didn’t look perfect, but it worked.  Then I added some online forms.  That way the patient’s didn’t have to fill out paper forms in the office.  Wow, was that hard.  I had to learn PHP (a web programming language used by lots of sites – including facebook).  That worked, except when people backed up.  It wouldn’t fill in what was already entered.  So – I learned Javascript.

I felt good.  My website works fine.  Except….when I search Google I can’t find it.  Its there, but not visible in searches.  Off I go to learn about SEO – search engine optimization.  I learn about meta tags and title tags.  I include more links and correctly using heading tags.

You know what?  It started to work.  My site showed up on some searches.  Then I made the mistake of comparing to other plastic surgery websites.  Most were very professionally done.  Some with video, most with impeccable graphics and dry but clear text.  Deflated, I looked again at my site.  It didn’t quite measure up.

Maybe I should pay the money for a commercial site.  Well, it cost about $10,000 for an elegant site.  Then another $4000 per year for SEO.  Wow.  I should be able to do better.

I tried again – fully determined.  I examined all of the parts of my favorite sites.  I picked the elements that I liked.  I enlisted the aid of my wife, a very artistic yet overly modest person.  I downloaded stock photos that were higher quality.  I used Photoshop to create pleasing backgrounds.

Finally, it looked about right.  I plan on publishing my home page today.  I also added a page for consultations.  And that is my start.  I’ll update all of the other pages as time permits.  I would like to have the new look complete by the end of August.  Then it will be off to my next project – YouTube videos.

They never taught any of this in medical school – HTML, PHP, Javascript, Photoshop, Google Analytics, Google Map Code, MySQL, SSL certificates, and so on.  Face lifts are easier!

The “Laser”

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I chuckle to myself when I think about lasers.  I expect Austin Powers to put air quotes around the word when I say it.  I find that many people use the term as if it was a magical device that can do anything – including make a scarless incision.  It can’t.  Lasers are just a way to apply energy to a spot.  All you can change is the size of the spot, the length of time the laser is on, and the color (and thereby the energy) of the laser.  That’s pretty much it.  (Physicists have a term called fluence that measures the amount of energy delivered per unit area.  Higher fluence = more energy.  Don’t remember that or people will think you are a geek.)

My first experience with medical lasers was in 1984.  I was a surgery intern and happy to be watching a case of hemorrhoids (yes, hemorrhoids) being removed with a laser.  The attending physician was proud to show me how his new toy worked.  He pointed the hand piece of the laser at a wooden tongue depressor and stepped on the pedal.  Sure enough – the laser beam immediately went right through the wooden stick.  Unfortunately it kept going, striking the paper drapes covering the patients legs.  Poof, a small fire started.  The nurse was totally calm and just dumped a basin of water on the smoking paper.  No harm done, but I realized that this was not a simple toy.

So what types of medical lasers are there and what are they used for?

The carbon dioxide laser was developed at Bell Labs in 1964.  It is an efficient laser that emits in the infrared part of the spectrum.  The wavelength of the CO2 laser is absorbed by water and therefore heats tissue very well.  It is used in facial resurfacing to remove wrinkles.  By controlling how long the pulse lasts and the pattern of pulses, very precise layers of skin can be removed.  It is often used with a computer pattern generator for perfect application of the pulses.

Nd:YAG is a type of laser also developed by Bell Labs in the same year.  Nd stands for neodymium.  The initials YAG is for yttrium-aluminium-garnet.  (Now you see why we refer to it by its initials.)  This laser emits infrared light (1064 nm).  It is used in ophthalmology and can be used to remove skin cancers.  Gynecologists use it during hysteroscopy to treat certain uterine conditions.  It’s most common cosmetic use is for laser hair removal and to remove spider veins from the face and legs.  It can also aid in removing fungus from the fingernails and toenails.

Er:YAG  is a similar laser.  Instead of neodymium, erbium is used.  This laser emits further into the infrared spectrum (2940 nm) and is strongly absorbed by water.  It is used in laser resurfacing of the skin to treat acne scarring, wrinkles, and melasma (patchy pigmented areas of the skin).  It also can be used to remove warts.  Dentists and oral surgeons use this laser to cut bone.

Q-Switched Lasers – Alexandrite, Ruby, Nd:Yag, Tunable Dye.  OK, another geeky term, but a very useful technique.  Q-Switching allows the laser to have high energy pulses instead of a continuous beam.  That makes these lasers ideal for tattoo removal.  From the Wikipedia article on tattoo removal:

  • Q-switched Frequency-doubled Nd:Yag: 532 nm. This laser creates a green light which is highly absorbed by red and orange targets. Useful primarily for red and orange tattoo pigments, this wavelength is also highly absorbed by melanin (the chemical which gives skin color or tan) which makes the laser wavelength also effective for age spot or sun spot removal.
  • Q-switched Ruby: 694 nm. This laser creates a red light which is highly absorbed by green and dark tattoo pigments. Because it is more highly absorbed by melanin this laser may produce undesirable side effects such as pigmentary changes for patients of all but white skin.
  • Q-switched Alexandrite: 755 nm. Similar to the Ruby laser, the alexandrite laser also creates a red light which is highly absorbed by green and dark tattoo pigments. However, the alexandrite laser color is slightly less absorbed by melanin, so this laser has a slightly lower incidence of unwanted pigmentation changes than a ruby laser.
  • Q-switched Nd:YAG: 1064 nm. This laser creates a near-infrared light (invisible to humans) which is poorly absorbed by melanin, making this the only laser suitable for darker skin. This laser wavelength is also absorbed by all dark tattoo pigments and is the safest wavelength to use on the tissue due to the low melanin absorption and low hemoglobin absorption. This wavelength is the wavelength of choice for tattoo removal.
  • Dye modules are available for some lasers to convert 532 nm to 650 nm or 585 nm light. Which allows one laser system to safely and effectively treat multi-color tattoo inks.

Dye lasers use an organic dye mixed with a solvent that is stimulated by an high energy external light source to lase.  Mirrors are used to increase the energy.  Then cavities or resonators are used to tune the output.  By selecting different dyes the output color can be changed.  They are commonly used to treat port-wine stains and other pigmented lesions of the skin.   The can also be used to decrease scarring and to make the skin tone more even.  By matching the dyes to the different ink colors they can also be used for tattoo removal.

IPL is the last one to discuss.  Intense Pulsed Light is technically not a laser.  It produces very high intensity light in very short pulses.  IPL is the most common form of hair removal ‘laser’ and is roughly as effective as the Nd:YAG mentioned above.  It is also used to treat rosacea, birth marks, sun damaged skin, and scarring.

And that should do it for today.  You are now more educated.  Enjoy!

 

Laser hair removal
Laser hair removal