Upper pole fullness is the term plastic surgeons use to describe the desired shape of the upper part of a breast.  Many women like the look of some upper pole fullness.  The challenge for us is how to make this shape during surgery, and have it stay there.Certainly, breast implants are a proven way to get upper pole fullness.  Moderate and high profile implants, whether they are saline or silicone gel filled, clearly create that fullness and roundness.  I  call this “the implant look”.Fact is, it is a real challenge to get the uplifted “implant look” without using breast implants.  Not that surgeons haven’t tried:  if you look at the literature on breast lifts and breast reductions, there are literally dozens of strategies that have been tried.  There are the “internal bra” methods, the internal suture methods, internal tissue re-arrangments, and many more.  These may very well work for the first month or two, especially while the breast is still swollen from surgery – but the real question is, do they last once the swelling has gone?

Dr. Elizabeth Hall-Findlay, the talented plastic surgeon from Canada and author of a textbook on surgery of the breast, did her own experiment on this problem.  She tried virtually every sensible method during breast lift surgery to try to solve the mystery of how to get persistent upper pole fullness without an implant.  She presented her results at a recent plastic surgery conference.  She found that, although the results looked promising initially, by 6-12 months after surgery, the shape of the breast returned to what it was pre-operatively, and that the fullness was lost.  Nothing really worked; all of the methods she tried failed to give lasting upper pole fullness.

This month, in PRS, comes a new study reviewing 82 major previous publications in breast lift surgery.  Careful photometric analysis was done of the techniques.  Once again, it’s a disappoinitment.  With the possible exception of fat-grafting to the breast, the author found that  upper pole fullness “was not increased by any of the mastopexy / reduction techniques, or by the use of fascial sutures or autoaugmentation techniques”.

In other words, all the methods touted for upper pole fullness failed to work.  So put internal lifting sutures, auto-augmentation, and the “internal bra” on the scrap-heap of discredited methods.

What does this mean for patients?  Simple:  if you want the “implant look”, you have to have an implant.  Fat grafting might be an option, too – but we’re still waiting for the studies on that one.

Observant readers will have noticed that I recently took a little break from blogging- and you’re right.  I’ve been working on a manuscript for the Aesthetic Surgery Journal, which is one of the most respected journals in our specialty… and I just finished it and submitted it to the journal today.  Hopefully, with a little luck, the editors will like my paper, and we’ll be seeing it in print in a few months!

So now, I can get back to blogging about new and cool developments in plastic surgery, as we usually do here at PSB: the Plastic Surgery Blog.  New stuff coming soon!

Today, at the annual meeting of the American Society of Plastic Surgeons, a new public service campaign was unveiled. It’s called “Do Your Homework” – and it refers to the selection of a properly trained and credentialed plastic surgeon for any elective plastic surgery.”Patients are getting injured, some are dying during procedures performed by non-board-certified plastic surgeons,” said Malcolm Z. Roth, MD, ASPS President. “We want patients to understand what to ask their doctor and what to look for so that they can maximize their chance of a safe and successful procedure.”As we’ve discussed before on this blog, most states do not have any laws that prevent doctors from practicing outside of their field. Recently, with more and more non-plastic surgeons starting to dabble in plastic surgery, it’s become a significant problem for consumers. And as we’ve discussed recently, people are being harmed by inadequately-trained operators. Only California, Florida, Louisiana and Texas have Truth-In-Advertising laws which require medical providers to be more honest about their training, or lack thereof. Sadly, here in Florida, these regulations are under-enforced.”There is a misconception among consumers that as long as a doctor is certified in a medical field that he or she is qualified to practice plastic surgery. This is absolutely wrong and it is dangerous for patients,” said Dr. Roth.

According to my colleague, Dr. Steven Teitelbaum, “What should happen is that every state medical board should say, ‘if you’re trained in pediatrics you are allowed to practice pediatrics and if you’re trained in orthopedics you can practice orthopedics.’ But, unfortunately, most state laws and regulations enable some physicians to drift into the practice of plastic surgery without proper training and certification.”

If you are not sure whether a prospective plastic surgeon is board-certified in plastic surgery, an on-line “find-a-surgeon” service is available from the ASPS.

BDD, or body dysmorphic disorder, is a problem in which the patient’s own perception of the body or body part doesn’t match the objective reality. Technically, it’s defined by the DSM-IV as “an excessive concern with an imagined or slight defect in physical appearance, leading to significant distress or impairment in one or more important areas of functioning”. As you might expect, we see this issue in our offices among potential cosmetic surgery patients.

Typically, most estimates state that BDD occurs in about 2% of the general population. In most cosmetic surgery offices, that number is probably higher – maybe 10% – due to self-selection of the patients. Now, a new study in this month’s issue of PRS (Plastic & Reconstructive Surgery) suggests that the number may actually be dramatically higher than previously thought in rhinoplasty patients. The new study suggests that one out of three patients (33%) has “at least moderate” symptoms of BDD.

OK, you might say, “so these patients are obsessed with the shape of their nose…isn’t that why you guys are there?” Actually, it turns out that it’s a bad idea to operate on these patients. Even though their nose may look better to you and me, it doesn’t fix their body image. Their self-image is still abnormal after surgery, and they are typically never happy with the surgical result, and have a higher rate of surgical revisions. Furthermore, the BDD patient’s quality-of-life actually deteriorates after surgery. Some BDD patients have even become violent after surgery. So generally, most surgeons try not to operate on patients who have obvious BDD. They need counselling, not surgery.

In this new study from Belgium, 226 patients seeking rhinoplasty were given a standardized questionnaire that had been developed together with psychiatrists, and the results were compared to a control group from the non-cosmetic ENT patient population. The two groups were comparable statistically.

The rhinoplasty group included some patients who wanted improved breathing, and some patients that wanted a better appearance. Overall, 33% of rhinoplasty patients scored high enough on the questionnaire to indicate moderate symptoms of BDD. This increased to 43% when only the aesthetic rhinoplasty patients were evaluated, and 12% in the airway (functional) group. Both of these scores were higher than the 2% seen in the control group. Note: the authors didn’t say that these people had the full blown BDD syndrome, just symptoms of a partial BDD situation.

Not surprisingly, there was no correlation between the objective and subjective evaluation of the nasal deformity…in other words, the patient’s view of themselves was very different than what the professionals saw on examination. This is what would be expected from the definition of BDD.

One more thing: in this study, the famous “SIMON” pattern did not hold up. (“SIMON” is a stereotype of BDD – rhinoplasty patient – the “single, immature male, overly narcissistic”). This study showed an equal prevalence in males and females. Another bit of long-taught surgical lore bites the dust.

Wondering if you have some BDD symptoms? Try this screening questionnaire.

Compared to other areas of our field, skin care often lags behind when it comes to good science. That’s one reason why an article in this month’s issue of ASJ (the Aesthetic Surgery Journal) is exciting: it looks at the effect of the Obagi skin care system in a good quality study. Here the study focused on the combination effect of Obagi in patients receiving Botox for facial wrinkles.

I’ll skip to the bottom line for you: the Obagi system, with additional Retin-A, significantly improved fine lines, wrinkles, and hyperpigmentation, leading to higher patient satisfaction ratings in patients who combined the skin care system with Botox treatments. It’s a winning combination.

Here’s one of the many charts from the article, showing the higher patient satisfaction scores with Obagi and Retin-A, compared to a standard skincare regimen. You don’t have to be a statistician to see the difference here!

“The new hydroquinone system is not only effective, it is also easy for patients to use, increasing the likelihood that they will be able to get maximum benefits,” said study co-author Joel Schlessinger, MD, FAAD, FAACS. “Most importantly, using the system in combination with tretinoin significantly improved how patients perceived themselves, which is the ultimate goal of any aesthetic treatment.”

When the FDA re-approved silicone breast implants for general use, back in November of 2006, one of the conditions was that the two major manufacturers and the FDA would co-operate to do some ongoing follow-up studies about implant safety and effectiveness. Now, approximately 5 years later, the FDA has released an update, discussing the first installment of this data.

In a nutshell: it confirms what we knew 5 years ago. Implants, when used correctly, are safe devices…but they’re not perfect.

The report says the same things we tell patients at their consultations for breast augmentation

1) Implants don’t last forever. They get old, become brittle, and eventually need to be replaced. This means more surgery, at some point in the future.

2) They can get in the way of mammograms. Other imaging techniques, like MRI and ultrasound, are very helpful in examining the implant and hard-to-see breast tissue.

3) The implants can get hard, due to capsular contracture, in a minority of patients. This is still the most frustrating, unsolved problem of breast implant surgery, long-term.

And these issues are also true for saline filled implants, as well.

Good news: the FDA study continued to find no linkage at all between silicone gel implants and breast cancer, or between silicone gel breast implants and auto-immune diseases, such as lupus, scleroderma or rheumatoid arthritis.

The FDA website has much more details. Their consumer page is here.

Here are my choices for the “Hot Topics” presented at the Boston ASAPS meeting:
1. “Stem Cell Facelift” – Dr. Peter Rubin reviewed the literature on the so-called Stem Cell facelift. It turns out that there really is no consistent technique for this method. Many advertised “stem cell facelifts” are simply regular facelifts with regular fat grafting and don’t involve any extra stem-cell work at all. Furthermore, to date, there is NO DATA that this technique is superior to facelift with standard fat grafting. Summary: as of today, the stem cell facelift can either be considered unproven and under development, or if you are a little more cynical, it might just be “marketing hype”.

2. Biofilms & breast implant contracture – as we’ve discussed here before, evidence continues to accumulate that there is a link between bacteria, which go on to form a slimy biofilm, and later development of a hard, contracted breast implant. Australian surgeon Dr. Anand Diva presented data from an animal study, showing that in their experimental model, once a biofilm was formed, that 80% of the animals went on to form a capsule around their implant. Furthermore, when an antibiotic-impregnated mesh was placed in the pocket with the implant, there were zero contractures, despite purposely contaminating the pocket with a dose of bacteria. The mesh, made by a company called TyRx, is currently in studies as a method to prevent infections around cardiac pacemakers. So far, no human studies have been done with breast implants and this mesh – but it’s clearly very interesting and exciting.

3. High Intensity Frequency Ultrasound (HIFU) – Dr. Mark Jewell presented his data on the Liposonix machine, which is claimed to reduce abdominal fat without invasive surgery or injections, but just an external treatment which focuses ultrasonic energy on the fat. It turns out that it works….but there are some limitations. In their study of 180 patients, an average reduction of 2.5 cm (1″) in abdominal circumference was seen after only one treatment. Some patients (good responders) had more than a 3 cm reduction in circumference. Treatment pain was rated as “none or mild” in 67%. Again, this machine is not FDA approved yet…but it’s available in Europe. Hopefully, we’ll get it one of these days!

Lots of cool stuff….more to come. It’s also been nice to catch up with friends from Boston and from Ann Arbor.

It’s nearly time for the annual Aesthetic Society meeting! This year, it’s being held in Boston, which is familiar ground to me! Plastic Surgeons from around the world will be there, discussing all the latest trends, hot topics, and new innovative devices and procedures. It’s the biggest meeting of the year for aesthetic plastic surgeons.

I’m hoping to hear more about:
– new, improved methods of fat grafting
– High-intensity ultrasound for non-surgical fat & cellulite treatment
– improved EMR’s for plastic surgeons
– new cosmeceuticals, filler agents and other cool stuff!

And as always, I’ll file a “Best in Show” report for the loyal readers of PSB- the Plastic Surgery blog! I’ll give you the insider report on what’s hot, and what’s not in plastic surgery. Stay tuned!!

The pieces of the puzzle regarding fat grafting for breast reconstruction and breast enhancement keep coming in, a little at a time. Here is a press release from ASPS, which summarizes a recent French study on mammography after the micro-droplet method of fat transfer to the breast, which was published in the recent issue of PRS. In short, fat grafting in this study did not get in the way of interpreting a post-operative mammogram.


ARLINGTON HEIGHTS, Ill. – Lipomodeling – a relatively new approach to breast augmentation in which fat is transferred to the breasts from other parts of the body – doesn’t interfere with routine screening mammograms, reports a study in the March issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

“Radiographic follow-up of breasts treated with fat grafting is not problematic and should not be a hindrance to the procedure,” concludes the new study, led by Michaël Veber, MD, of University of Lyon-Léon Bérard Cancer Center, France.

Originally developed for breast reconstruction surgery, lipomodeling is now being used by some plastic surgeons for cosmetic breast shaping. In this procedure, small amounts of fat are taken from one part of the woman’s body (such as the hips or thighs) and transferred (grafted) to the breasts. The new study was designed to determine whether lipomodeling caused any problems with routine mammograms to screen for breast cancer.

First, the researchers reviewed mammograms performed an average of 16 months after lipomodeling in 31 women. In more than half of cases, the mammograms showed no abnormalities.

Some women had small calcifications or cysts as aftereffects of the fat transfer procedure. A few women had other abnormalities related to scarring from their breast surgery. However, none of these changes were considered likely to raise suspicions of breast cancer on routine mammograms.

Dr. Veber and colleagues then analyzed mammograms performed before and after lipomodeling in 20 women. Based on standard criteria, there were no significant differences in the mammographic results from before to after the procedure. In particular, there was no increase in abnormal results that would spur suspicion of breast cancer.

There were no major changes in breast density after lipomodeling. Perhaps most importantly, it was no more difficult to perform and interpret follow-up mammograms in breasts that had undergone the procedure.

Although the study is only preliminary, it provides important information for health care professionals performing mammograms in women who have undergone this new approach to breast augmentation. Dr. Veber and coauthors suggest that women undergoing lipomodeling have a complete evaluation-including mammograms-before and after the procedure. This will provide reassurance that any new abnormalities are a result of the lipomodeling procedure, rather than a possible sign of breast cancer.

My thoughts: fat transfer to the breast is an exciting new option for women for both reconstruction and augmentation. But it’s a lot different than using implants. I’m part of an IRB-approved study for this technique. One of the key factors for success of this process seems to be the preparation of the breast, otherwise the fat just disappears. So far, the BRAVA system, cumbersome though it is, seems to really help in this way. Also, the surgeon has to be very particular about the harvesting and injecting methods. The various methods are certainly not all the same, in terms of how well they work. This particular study used the Coleman system.

I’ll be attending a workshop on this topic in Boston in early May. I’ll report back with all the latest details!!

I participate in a number of online question-and-answer boards about Plastic Surgery, including “Ask-a-Surgeon” from ASAPS and Realself.com

Today, this question came up: Is smart lipo/laser lipo better than traditional liposuction? What credentials should I be looking for in my doctor if I was interested in this procedure?

Here’s my answer: Getting good results in liposuction is not related to the machine used, it’s related to the surgeon who is using the machine! For example, if you had the paintbrush that formerly belonged to Leonardo da Vinci, would you suddenly paint a masterpiece? Probably not.

There are no scientific studies that have been able to show a significant improvement in results with laser-assisted liposuction, or water-jet liposuction, or any other type of liposuction. They all work about the same. The only difference is the tremendous marketing spin that has been applied to the laser machines by the companies that manufacture and sell them.

Find a board-certified plastic surgeon that does a lot of liposuction, and study their before and after photos. Have realistic expectations. Find out if your skin elasticity is suitable for the procedure ….remember, liposuction doesn’t predictably tighten skin.

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