Seattle Plastic Surgeon shares some great news about Type 2 Diabetes.

For years it has been observed that obese patients with Type 2 diabetes have a dramatic improvement in their diabetes after gastric bypass surgery.   And this improvement is seen almost immediately after surgery, long before the patient loses significant weight.  Now there is something more that just anecdotal reports of this finding.

Recently the results of a randomized, prospective study of 150 obese, type 2 diabetic patients treated with  surgery or intensive medical therapy was released.  This study was carried out at the Cleaveland Clinic and took a look at the blood sugars of patients one year after surgery vs. one year after intensive medical treatment. 

The surgery patients blew the medical patients out of the water with their blood sugars going down, way down, despite stopping their diabetes medications. 

This study confirms the many anecdotal reports of the past decade or so.  Could it be that the first line of treatment for this devastating disease that afflicts so many obese patients will be major surgery?   It’s too soon to tell but as these types of surgical weight-loss procedures become safer and safer, that just may end up being the case. 

Now we just need a fix for obesity that triggers most cases of Type 2 diabetes.    Send me your ideas for this.  I’d love to be in on it. 

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon is seeing some very nice results from fat transfer to the breast.

Left side : before fat transfer. Right side : 3 months after fat transfer. She has gone from a B to a C cup.

It takes quite a bit to get me enthusiatic about “new stuff” because “new stuff” pops up every day and more often than not, the reality does not begin to live up to the hype.  This tends to make one (me, for instance) a bit skeptical. 

As discussed on my website and previous blogs, fat transfer to the breast is a new procedure that I am now offering to very carefully selected patients.   And now I am starting to get some sort of longish term follow-up and I am starting to get, well, a little bit excited.

This lovely mother of two darling boys had her fat transfer last fall and her size is holding steady.  She was a B cup before transfer and a C cup three weeks after transfer and today is a C cup three months after transfer.  She is thrilled and so am I. 

She not only has no implant to maintain, she has virtually no scars on her chest and she has a subtle improvement in her breast shape.  No, she’s not going to stop traffic with this chest but that was never her intent. 

And another cool thing about fat transfer – it’s really a twofer.  In this patient’s case, I took the fat off of her posterior hips and she is much slimmer in that area and with the increase in her breast volume, is much better balanced between her upper and lower body.  SWEET!

Thanks for reading!  Dr. Lisa Lynn Sowder

Strattice is very, very useful for difficult implant revision cases. It provides soft tissue coverage and position control for breast implants. It acts like an internal push-up bra. Sweet, huh?

Seattle Plastic Surgeon is really, really loving the acellular dermal matrix, Strattice.  So are her challenging breast implant revision patients.

In the past two months, I have been getting a lot of experience with Strattice, which is an acellular dermal matrix.  Sounds very complicated, huh? 

The concept is not complicated at all.  Strattice, which feels a lot like the chamois you may use to polish your car, acts like an internal bra.  It supports the breast implant the way a bra supports the breast.  It also provides some additional soft tissue coverage for the implant which is really nice in thin women.  And there’s more!  It appears that Strattice reduces the chance of the dreaded capsular contracture by altering the body’s scarring mechanism around the implant.   And there’s even more!  Strattice, which is made from pig skin, is eventually replaced by the patients collagen.  Like the term “acellular dermal matrix” implies, the Strattice acts as a scafold for the patients own tissue.  And yes, there’s even more!  Even though Strattice comes from pigs, none of my patients have sprouted  curly tails.

The downside?  Using Strattice is a little tricky and it adds O.R. and anesthesia time.  Also, it’s expensive but not as expensive as an additional breast implant revision.   

Time will tell if Strattice is really my new best buddy, but so far it’s looking very, very promising.  And, by the way, I get no, nada, zero, zilch $$$ for saying nice things about this or any other product. 

Thanks for reading.  Dr. Lisa Lynn Sowder

Top shows the back of the hand before fat transfer. Bottom shows the back of the hand after fat transfer.

Seattle Plastic Surgeon just can’t keep her opinion about this poorly thought out procedure to herself. 

I read several plastic surgery journals every month and more often than not I think, “Now there is a good idea”.  But this month I read an article about using a “hand lift” for hand rejuvenation and I thought, “Now there is a really, really bad idea”.

 A “hand lift” involves excising some of the loose skin at the level of the wrist and pulling the skin on the back of the hand tighter.  Yikes!  This not only leaves a significant scar on a very visible area of the wrist but also makes the skin too tight when making a fist.  And it doesn’t help the quality of the skin itself. 

The problem with the idea of a “hand lift” is that it does not address the real problems with aging of the hands.

So what was this plastic surgeon thinking when he thought up this operation?????   My guess is that he did not know how to perform fat transfer to the hand which is a procedure that I think is really, really great.  Fat transfer addresses some of the real problems with aging of the hands: deflation because of loss of fat and deterioration in skin quality. 

With fat transfer to the hand, fat is harvested from the patient where there is a relative excess (usually the belly or the hips).  The fat is purified and then injected into the back of the hand in teeny, tiny parcels.  The fat does a couple of things.  First of all, it plumps up the hand that has lost fat over the years and second, it really improves the quality of the skin.  Just take a look at these close up photos.  Not only are the veins less prominent after fat transfer, the fine lines are much, much smoother and the color of the skin is better.  These changes are likely due to the stem cells that are in the fat.  This change in skin quality is seen in other areas when fat is transferred to the layer just under the skin.   This stem cell effect is a very, very hot topic and is being investigated by several large plastic surgery institutions.

Soooo, if you don’t like the way your aging hands look, don’t get a “hand lift” but consider fat transfer instead.  There are no long scars and recovery is usually quite rapid and almost painless and the improvment is long lasting.

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon has been waiting almost 18 years for some additional real  research on laser-assisted liposuction. 

I recently read a letter to the editor in Cosmetic Surgery Times.  This glossy “journal” arrives in my mailbox monthly and is often fodder for this blog, especially when I am exposing misleading before and after photos. 

This month’s edition included a great letter from Dr. Peter Fodor about a multicenter clinical study of laser-assisted liposuction he and several other plastic surgery colleagues did way back in 1994.  They performed liposuction on a bajillion patients and used traditional liposuction (TL) on one side and Laser-assisted liposuction (LAL) on the opposite side and then, after healing, had the results assessed by a neutral observer and the patient, neither of whom knew which side was the TL side and which side was the LAL side.   This was a well designed blinded and controlled study.  

The results:  “The investigators came to the unanimous conclusion that LAL was not an advantageous trade for TL.  The results were not superior, while the expense, learning curve and cumbersome nature of the procedure were rather steep.  The company wisely withdrew the device from large-scale commercial distribution.”

Fast forward to 2011:  Currently availiable LAL devices include SmartLipo, CoolLipo, ProLipo/Plus, LipoForm, Lipotherme, SlimLipo, LipoPulse, Gold Lipo, SmoothLipo, and AccuSculpt.  Have any of these devices undergone the scrutiny of that LAL  device from 1994?  Noooooooooo.  Are these newer devices being aggressively marketed to every sort of doctor who wants a piece of the liposuction action (and sometimes marketed directly to prospective patients)?   Yesssssssss.  And are these devices and their often inexperienced users responsible for most of the poor and often untreatable liposuction outcomes?  Yessssssss. 

Dr. Fodor reminds us that:  ”Just as in playing tennis, other sports or music, it is not the racquet, musical instrument or surgical device that plays the primary role in the quality of the performance, it is the person in control that matters the most.”

Thanks for reading.  Dr. Lisa Lynn Sowder

Seattle plastic surgeon, Dr. Lisa Lynn Sowder, fondly remembers her Polaroid camera.

This week I have seen a couple of patients whom I operated on way back in the early 1990′s.  We found their charts down in our storage room and in those charts were their Polaroid photos – a little faded but with pretty decent definition. 

Back in those days, I took two sets of photos: one with my Polaroid and then color slides with my Minolta SLR that weighed about as much as a Gorditos Burrito. 

About 15 years ago, I switched over to digital photography and a photo archiving system on my computer.  Storage and retrieval and duplication of photos is so much faster and easier. 

But the most beneficial effect of my new system is that it allows me to really scrutinize my before and after results. There is no waiting for the film to be developed and I don’t need a light box and my magnifying glasses.   Nowadays I see the results, right away, front and center and really big on my computer screen.  This sort of visual feed back is essential for plastic surgeon evolution.

I do miss my Polaroid a little bit.  It made for such a great party camera.  Does anyone else remember how fun it was to watch the picture develop? 

Thanks for reading!  Dr. Lisa Lynn Sowder

Breast enhancement with your own fat? Well, maybe.

Seattle Plastic Surgeon, Dr. Lisa Lynn Sowder adds her two cents worth about fat transfer to the breast.

One of the hot topics at the annual meeting of the American Society for Aesthetic Plastic Surgery(ASAPS) in Boston which I attended last week was fat grafting to the breast. This procedure has a very interesting history.  Back when the earth was cooling and I was training to become a plastic surgeon (1983-1991), fat injections were considered fringe surgery and fat injections to the breast were for all practical purposes panned by the American Society of Plastic Surgeons (ASPS) and ASAPS.  Fat  injections to the breast were considered ineffective and dangerous. Well, that was then and this is now.

Fat grafting is now a well established procedure that has been used for facial rejuvenation, hand rejuvenation, the treatment of liposuction divots, buttock enlargement and a few other indications. Much of the early work done with fat grafting was performed by Dr. Richard Ellenbogen in L.A. and Dr. Sydney Coleman in New York and these two doctors were subject to ridicule and disbelief for several years. I remember in 1993, when I took my plastic surgery board exams, the correct answer to any question about fat grafting was that it didn’t work.   That is not the correct answer any more.

Fat grafting to the breast started with surgeons, myself included, using fat around the periphery of a reconstructed breast. For example, if there were contour defects at the edges of a breast reconstructed with an implant, some fat would be used to smooth that area out. Then we started using it for patients who had thin areas anound the breast following cosmetic breast augmentation.

Now we are using fat injected into the breast itself for breast enhancement. After taking several instructional classes on this topic in Boston, I am convinced that this is an appropriate and safe procedure for a very select group of  patients.

Fat injection, at least currently, will not acheive the same volume of enlargement that implants can.  Most fat injected breasts go up only one cup size. That eliminates a lot of ladies wanting to go a lot larger.  One of the doctors who spoke in Boston (and who has the most experience with cosmetic fat transfer to the breast) still uses implants in 90% of the patients who present to him for breast enhancement and uses fat in only 10%.

For the best results in patients with very tight breasts and chest tissue,  it is necessary for the patient to undergo breast expansion to stretch the breast and skin and to increase the breast vascularity prior to the fat transfer. This is done using a gigantic breast pump called the Brava System.

They should have called it the Brave System because it takes a brave lady to strap one of these babies on and then go out grocery shopping. The plastic surgeons who have the best results in thin, tight patients with fat grafting have their patients wear the Brava 10 hours a day for about 4 weeks. This is no small task. This Brava requirement also eliminates some patients wanting fat grafting. The experts (and who am I to question them?) tell these patients who want fat grafting “no Brava, no breasts”.

For patients who have experienced breast atrophy following breast feeding or weight loss, the tissues are loose and this preoperative stretching is not as important.  These patients will likely do okay without the Brava.

My week in Boston at the ASAPS meeting really opened my mind to this new way to enhance the breast and I am looking forward to offering this procedure to selected patients. But remember,  if you are “tight” – “no Brava, no breasts”.

I am really on a roll here, or maybe it’s a rampage. It’s too soon to tell. Here is another “before and after” from yet another liposuction gizmo that is supposed to sculpt the fat layer and tighten the skin layer, all without surgery!

Take a close look at these photos. They are pretty impressive, don’t you think? But take a really close look. Mentally drop a straight line down from the point where her nose meets her upper lip. Then take a look at her chin. Her chin (AS IN CHIN BONE) has been moved forward. This ad thus implies that this non-surgical fat sculpting and skin tightening gizmo can actually move a chin and jaw bone. Maybe this lady’s chin and jaw were moved but if so, it was done using an orthognathic surgical procedure and it involved a bone saw and some metal screws and plates. Not exactly non-surgical or minimally invasive. Or maybe the ad folks just used Photoshop. Either way, this ad is more than highly misleading. It is fraudulent.

And again, the wretched thing is that these gizmos are heavily marketed to those without full training in Plastic Surgery. And those wannabe “plastic surgeons” who may be saying, “Wow, what a great result. I must have one of these!” don’t even know what orthognathic surgery is. I sure didn’t know it existed until I did my plastic surgery training.

Orthognatic surgery, by the way, is a field of plastic surgery and maxillofacial surgery which involves moving the bones of the face, usually the upper and/or lower jaw. And it’s not done with a “minimally invasive”, one bazillion dollar, fraudulently advertised gizmo with a “doesn’t know any better” doctor pushing the button.

I get buried in advertisements for the newest, latest, greatest, you gotta have it, gizmos that are supposed to make my practice and my results and my life in general even better that they already are. Of course, these gizmos average about $100,000 and – this is what really fries me – they are rarely available for demo prior to purchase. This is sort of like buying a fancy new car without a test drive.

Another thing that fries me is some of the very, very misleading advertisements that many of the manufacturers try to pass off as real results. Here is an example. This is from an ad for a non-invasive fat removal system that uses energy that passes through the skin and is directed at the fat layer. Wow, what a difference until you look carefully. (Plastic surgeons are trained to look carefully.) In the photo on the right, Mr. Sixpack is pinching a fat roll that starts above his bellybutton and in the photo on the right, he’s pinching a fat roll that starts below his bellybutton. So obviously the more fat pinched, the thicker the roll. I can do this myself – big fat roll and little fat roll. I bet you can do it too!

Okay, and just one more thing that fries me, and then I’ll stop, at least until my next blog entry: Most of these new technologies are marketed heavily to non-plastic surgeons. The family practice doc or gynecologist or even (I’m not making this us) ophthalmologist who may want a little piece of the cosmetic surgery action may see this ad and go, “Wow, I must have one of these!” These docs are not experienced with liposuction or other body contouring and may not look at these photos as carefully as a real plastic surgeon. So these non-plastic surgeons buy one, it doesn’t work very well but they have to keep promoting it and using it and in some cases, giving patients a really raw deal because they have already dropped $100,000 on it and they can’t sell it because after a while, everyone knows it doesn’t work very well. So beware of non-plastic surgeons using the “latest technology”. They likely just don’t know any better.

Recently a laser manufacturer surveyed some 65 tattooees in a Los Angeles shopping mall. They had two questions. 1. At what age did you get your first tattoo? 2. Do you regret getting your tattoo? Look at these results:18 or younger: 71% with regrets19-25: 14% with regrets26-35: 14% with regrets over 36: 0% with regrets SOOOOO……..If you are 18 or younger, just wait a few years or you could be in for some big time regret and some big time $$$$$ for removal. And removal is never perfect. Even the most advanced lasers leave some textural changes in the skin.

I’ve told my three kids that I’ll give them $1000 on their 20th birthday if they are tattoo and piercing free (except for my daughter’s earlobes).

Something about the above photo and survery reminds me of something really smart George W. Bush said. “When I was young and stupid, I was young and stupid.” Wise words, W.