Blog — Notes of a Plastic Surgeon

Welcome to my blog. I am a plastic surgeon in Seattle and have been in private practice since 1991. I've seen more than a few interesting faces and cases through my years spent in the exam room, the operating room and the emergency room. And I have an opinion on just about everything relating to plastic surgery (and a lot of unrelated stuff). If you like my blog, let me know. Thanks for reading! Lisa

Halloween Owl is a Mother’s Friend

October 29th, 2019 — 12:20pm

Happy Halloween!

blog halloween owl

“I’ve come for my candy.”

If you have young kids at home, you need to meet the Halloween Owl.  He is your best friend this time of year.

This is how he operates.   You help your  children set aside at least half of their sugary treasure to donate to the Halloween Owl.  They put their donation into a nice decorated paper bag with “Halloween Owl Only” written on it with big black letters.   After the children are in bed, their tummies aching from all of that crappy candy, the Halloween Owl taps on the window to claim his share of the bounty which he shares  with all of his woodland friends.    There is little pushback from the children as they imagine the owls and raccoons and possums enjoying their once a year treat.  And in Seattle, where I live, there are occasionally reports of coyotes in the city limits and once a report of a cougar in one of our city parks.   Those are big critters and they need lots of candy and the children may be even more generous with their donation.

My children are young adults now and they are wise to the Halloween Owl but it worked great for years.  So if your kids are young, give it a try.  Just make sure that you put the candy at the very bottom of the garbage can.

Thanks for reading and i would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.   Dr. Lisa Lynn Sowder

Children, Now That's Cool

“It’s All in Your Head”—Medicine’s Silent Epidemic

October 11th, 2019 — 8:18am

A fascinating article about the mind-body connection.  This is from a recent Journal of the American Medical Association.  

 

Viewpoint

September 16, 2019

“It’s All in Your Head”—Medicine’s Silent Epidemic

Matthew J. Burke, MD, FRCPC1,2

Author Affiliations Article Information

JAMA Neurol. Published online September 16, 2019. doi:10.1001/jamaneurol.2019.3043

It’s all in your head” is a phrase sometimes said by physicians to patients presenting with symptoms unexplained by medical disease. As a neurologist specializing in neuropsychiatry, nothing bothers me more than overhearing medical colleagues proclaim this one-liner at the bedside or snicker about these patients during rounds. Unbeknownst to them, I also hear my patients’ version of being on the other end of this phrase and find myself constantly trying to repair the damage that these words can cause. Whether physicians like to admit it or not, medically unexplained symptoms encompass a vast terrain of clinical practice. In neurology, these symptoms fall under functional neurological disorder, but every specialty has their own variants and favored terminologies (eg, chronic fatigue syndrome, fibromyalgia). The inadequate management of this segment of medicine represents a silent epidemic that is slowly eroding patient-physician relationships, perpetuating unnecessary disability, and straining health care resources.

The irony of “it’s all in your head” is that although this phrase is often used inappropriately and dismissively, it is technically correct. The problem does indeed lie within the head. More specifically, it lies within the brain and its complex networks that we are just beginning to understand. Over the past 10 years, neuroimaging research studies have consistently identified brain abnormalities in patients with medically unexplained symptoms—yes, biologically based changes in the activity and connections of brain regions, such as the amygdala, prefrontal cortex, temporal-parietal junction, and other structures.1 These brain circuit abnormalities provide physiological explanations for once mysterious links between regions implicated in emotional processing and the generation of “physical” symptoms (eg, pain, fatigue, weakness). Jean-Martin Charcot, MD, a famous 19th century French neurologist and early pioneer of this field, reportedly insisted that a “functional lesion” would be found when microscopes were sufficiently powerful.2 Well, our microscopes are getting better, and we are now starting to see evidence of the predicted functional or software disruptions in the brain. We still do not fully understand what causes these software problems; however, recent research suggests a multifactorial etiology, including genetic predisposition, environmental risk factors (eg, childhood adverse events), and psychological stressors.3

Despite the growing scientific literature, there has been minimal shift in physician attitudes toward these patients. Physicians seem quite comfortable with the idea of structural brain lesions causing psychological symptoms, such as a frontal lobe stroke causing depression or a temporal lobe tumor causing delusions. However, the reverse causality of psychological factors (borne of the same substrates—neurotransmitters, neurons, and synaptic connections) leading to neurological or systemic symptoms is often hastily dismissed and remains highly stigmatized. Thus, many physicians either simply ignore these kinds of symptoms or wrongfully assume that patients are malingering.

Based on such attitudes, a typical physician-patient interaction may proceed as follows: (1) the physician provides a rundown of normal investigations, (2) the patient is told they have no known medical diagnoses, (3) a brief awkward exchange occurs, and (4) little further explanation, guidance, resources, or facilitation of an appropriate referral process is given. Even if the infamous phrase is not explicitly stated, this sequence leaves the patient to infer for themselves that it must be all in their head. Unfortunately, they do not perceive this as, “I have a real dysfunction of networks in my brain,” but instead understandably conclude that, “they think I’m crazy” or “faking it.”4 Sometimes, patients may hear the distant utterance of, “Maybe you should see a psychiatrist,” as they exit the office door, but in this context, such advice is rarely productive.

Many of these patients can be so offended by this encounter that they quickly seek multiple second opinions and subsequent rounds of pricey and unnecessary investigations. Depending on the jurisdiction and medical record system, the original physician may be completely unaware of these additional rounds of care. Mounting negative and invalidating clinical interactions can become a source of distress and cause medical trauma. At this point, patients often either fall through the cracks or stumble on a fringe medical specialist or alternative medicine practitioner who may offer the “physical” diagnosis they’ve been yearning for. This could include a growing list of unsubstantiated metabolic deficiencies, infectious disorders, or autoimmune hypersensitivities. Anecdotally, the most common current example seems to be the diagnosis of chronic Lyme disease by unvalidated assays.5 Let me be clear that many of these practitioners are well intentioned and can offer holistic approaches that medicine could learn a lot from. However, there appears to be a subset that take advantage of these patients’ desire for a “physical” diagnosis and exploit their vulnerabilities.

For the patient, receiving such a concrete, “organic” diagnosis often quells mounting anxiety, which in itself could be partially therapeutic. However, now wedded to their given diagnosis with no knowledge of their actual software problem, patients do not see a need to address underlying factors that may be contributing to their disorder nor do they receive the multidisciplinary care that they may so badly need. The saddest part of this epidemic is that if addressed early, these symptoms may be reversible; however, with delays to proper diagnosis and management, prognosis worsens considerably.6

So how can we prevent or interrupt this concerning trend? Often, the first step to addressing a problem in medicine is providing data to prove that the problem exists. This is where the challenge begins and what makes this a silent epidemic. The magnitude of this crisis is difficult to demonstrate because these patients largely elude the billing codes used for case ascertainment in large population-based studies. This is because of a combination of gaps in current billing and diagnostic codes (country specific) and because of the fact that codes are not being used appropriately by many physicians. The latter may happen for multiple reasons, including lack of comfort with these diagnoses and concerns of medicolegal ramifications.

Despite a few isolated efforts to estimate prevalence7 and health care costs,8 the evidence base needed to sway research granting organizations, government policy makers, and health care and insurance systems has been largely elusive. I am optimistic that it is only a matter of time until the scope of this crisis is fully appreciated. I see firsthand the high patient volumes and health care resource utilization that currently escape record keeping. I raise these concerns to my colleagues, who wholeheartedly agree, but the conversation ends there and the silence continues. I am hopeful that new research technologies, such as natural language processing, could identify these patients in medical records despite the lack of adequate billing code data and that improved records systems will better track these patients through different health care pathways.

To address the epidemic itself, we desperately need more clinicians and researchers dedicated to interrogating the complex interfaces of mind, brain, and health. Currently, there are small pockets in different specialties, but these are not nearly commensurate with the volume and impact of these disorders. Second, and arguably more importantly, we need to fundamentally change the culture within the medical community to eliminate the negative connotations associated with these disorders. This change requires buy-in from hospital and health care leadership and a supportive infrastructure. These patients have complex conditions and require additional upfront consultation time, resources, and collaborative care. To prevent the cycles described previously, physicians need to be incentivized to take the time necessary to optimize the initial patient encounter. This includes delivering and explaining the diagnosis in a transparent and supportive context,9 providing patient-friendly resources (eg, https://www.neurosymptoms.org/), and referring appropriately for interdisciplinary management (eg, physical therapy, occupational therapy, psychotherapy). New educational and training initiatives across medical and allied health professions will be critical for enabling a successful transition.

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Article Information

Corresponding Author: Matthew J. Burke, MD, FRCPC, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, KS-274, Boston, MA 02215 (mburke11@bidmc.harvard.edu).

Published Online: September 16, 2019. doi:10.1001/jamaneurol.2019.3043

Conflict of Interest Disclosures: Dr Burke is supported by funding from the Sidney R. Baer Jr Foundation.

Disclaimer: The content of this article is the opinion of the author and does not necessarily represent the official views of Harvard University or the University of Toronto (and their affiliated academic health care centers) nor the Sidney R. Baer Jr Foundation.

Additional Contributions: I thank Saadia Sediqzadah, MD, SM (Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada), for her helpful comments and review of the manuscript. Dr Sediqzadah did not receive compensation for her contributions.

Thanks so much for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  

Dr. Lisa Lynn Sowder

General Health, Highly Recommended Reading

A craaaaazy breast implant complication.

September 25th, 2019 — 3:19pm

I use my blog to share some of the interesting stuff I see in medical journals and this is one of weirdest case reports I have ever seen.  This is from PRS Global Open (from about a year ago) which is the International Open Access Journal of the American Society of Plastic Surgeons. See the original article here.

This is a 65 year old lady with 31 year old silicone gel breast implants.  She presented with massive swelling of her left breast. She first noted the three years previously following a car accident.  Apparently she initially sought treatment but because of insurance issues did not receive definitive care.  Her MRI scan showed rupture of her implant with extrusion of implant material outside the scar capsule (a so-called extracapsular rupture) and fluid and a mass.  Since this looked so creepy and suspicious for cancer, a biopsy was done with came back consistent with organized hematoma which is a benign collection of old blood usually secondary to trauma.

She was taken to the OR and she was found to have ruptured breast implants (not unexpected given their age) and a large blob of old partially solidified blood on the left side.  She had removal of the implants and blood blob and also had some skin reduction done on the left side.  From this seasoned plastic surgeon point of view, she has an absolutely stellar result.  She also had some silicone removed from her left upper arm.  It no doubt migrated there either during or shortly after the car accident.  It had not caused any problems but was a palpable mass.  It hard to believe that this lady had to live with for 3 years because of her insurance company dragging their feet!

Anyway, it’s always something and I’m grateful to the plastic surgery department from Duke University for sharing this really weird and really interesting case with a very happy ending!

Thanks for reading and I would be so happy for you to follow me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

Breast Implant Removal, Breast Implants, Now That's a Little Weird

Should you travel for breast explant surgery ?????

August 29th, 2019 — 2:00pm

This post is based on a phone consultation from earlier this week.  I’ve changed a few unimportant details to protect patient privacy.

That bag is gonna be a killer to get into the overhead bin after surgery!

This lady has smooth, saline implants that are about 10 years old.  She is part of the Pacific Northwest Breast Implant Illness (BII) Facebook group and she thinks her implants are making her ill.  Her augmentation was done by the (IMHO) very best plastic surgeon in her state who lives and practices in the patient’s hometown.  She has seen her plastic surgeon for explant and her plastic surgeon has agreed to do her explant and remove as much capsule as can be safely done.  So why, I ask, does this patient want to come see me???  Am I an explant expert?   Well, sort of in that I have done about a bajillion explants (mostly reasons other than BII) over the 28+ years I’ve been in practice.

But……………….explant and capsulectomy is not specialized surgery.  This is a procedure that just about any plastic surgeon who does a lot of breast surgery is capable of doing.  Now, I would not expect, say, a craniofacial surgeon to have any great expertise (or interest) in this but most “general” plastic surgeons are very capable of doing this.  Promoting myself for explant and capsulectomy is sort of like Gordon Ramsey promoting himself as the ultimate chef for grilled cheese sandwiches.

So how about the fabulous explant experts who can guarantee an “en bloc” and offer “detox” products?  Well…………………………….I’m not gonna throw anyone whom I have never met under the bus.  But I will say this:  There is zero, nada, zilch, nichts, niet, nula, noll, odo evidence that an en bloc resection is absolutely necessary or that detox does anything other than slim down your bank account.  It’s super nice (and sort of fun) to do an en bloc in cases of silicone gel rupture but there is no evidence in peer reviewed surgical literature that there is any difference in clinical outcome.  The same goes for cases of BIA-ALCL.  Would I recommend a careless surgeon who is not thorough or does not endeavor to keep things as clean as possible?  Of course not but I must say the vast majority of plastic surgeons are pretty damn thorough and meticulous.  It’s in our DNA.

We plastic surgeons are always ragging on surgical tourism and espousing the danger of going to a distant land for el cheapo plastic surgery but we should also be ragging on traveling within the United States for routine procedures.  Travelling adds a lot of complexity to the whole surgical process from initial evaluation to final follow up.

There are plastic surgeons being promoted as some sort of super experts by the breast implant illness activists.  I have zero evidence that money is changing hands but isn’t it a little weird that this sisterhood, who should want what is best for other women, to recommend traveling hundreds and sometimes thousands of miles for a routine surgical procedure?  Oh, and waiting sometimes up to a year to have their toxic bags of death removed?  And as for detox?  Zero evidence of necessity or efficacy. You can get your detox package from your local woo woo health provider who is happy to lighten your wallet.

So think global, buy local and support your probably very capable local plastic surgeon!  Just make sure your plastic surgeon is the real meal deal and certified by the American Board of Plastic Surgery.

Thanks for reading and I would be thrilled if you followed me on Instagram @sowdermd and @breastimplantsanity.

Dr. Lisa Lynn Sowder

Breast Implant Illness, Breast Implant Removal, Breast Implants, My Plastic Surgery Philosophy, Patient Safety, Plastic Surgery

Off to college? Words of wisdom.

August 26th, 2019 — 9:35am

Four years ago I sent my twin sons off to college. Last Saturday I help their little sister move into her dorm.  And then I cried.  A lot. 

For those parents doing this for the first time, second, third or fourth time,  and for all those lucky youngsters heading off to college, let me share this wonderful essay with you.

blog off to collegeCoping with the angst of dropping off your child at college by Kent Hickey.

From the Seattle Times, August 29, 2014.

All around the country freshmen are filling up suitcases for college. Their parents’ heads are filling up too, mostly with “remember when.”

As we prepared to send our first off to college, my mind kept revisiting all those Saturday mornings in parks when our kids were little. They loved to sneak acorns into my pockets and run away laughing as if they had pulled off some grand caper. One day I caught the eye of an older gentleman as he walked by. “Enjoy it while you can,” he said. “This passes fast.”

It has. And that first college drop-off was a big moment for all of us, especially for our daughter, though one likely eclipsed by that even bigger moment when she finally received the highly anticipated and much practiced “Dad’s Wisdom for College” talk.

I found the perfect setting a few days before departure: a car ride to the grocery store, doors locked and vehicle in motion to guard against the inevitable triggering of the daughter’s flight response.

Here it is:

“Introverts draw energy from solitude. Extroverts draw it from company. Know who you are and find your balance.

“Dads are awesome; boys are not. Always do what Dad would think is right. Never do what a boy thinks is right.

“The single most stupid thing done in college is almost always done while drunk. And, while getting high on marijuana may not necessarily lead to doing equally stupid things, it will lead to doing fewer things. Don’t be stupid.

“God has been a friend in your life every day, whether you’ve known it or not. Bring your friend to college with you and spend time with your friend every day.

“You will never really leave your home.”

It’s hard to say what the daughter took from these pearls, especially with all the other messages, often mixed, that young people hear as they prepare to head off for college:

Explore, find yourself; just make sure you earn a marketable degree that guarantees high lifetime earnings. Don’t be afraid to meet new people, but be wary given all those sexual assaults on campuses. Become a lover of learning without obsessing over grades, though they will likely decide your future.

Colleges are now keenly aware of how hard the drop-off is on my generation, the baby boomers. Upon our arrival on campus the daughter was quickly immersed in her orientation. The same experience awaited parents. I’ve never felt so nurtured, or exhausted.

There were days of parent orientation, each session starting with a “Relax, it will all be fine.” Heck, the school’s president even gave out his personal cell number, just in case we needed to chat, and I don’t even think it was fake. When did we become so needy?

My folks, who were of the World War II and Korean War generation, drove me from our home in Kalamazoo, Mich., to Marquette University in Milwaukee 35 years ago. We had one stop along the way, at the Mars Cheese Castle in Kenosha, went straight to my dorm upon arrival and quickly deposited the contents of one suitcase in my room.

Then Mom gave me a tearful hug, Dad an awkward handshake. Right after I moved in, they moved on. No dayslong orientation for them, and hardly one for me. My first lesson was given that very night by two sailors who tried to mug me when I got lost in an alley behind some dorms. I ran away and hid in a dumpster. A passing grade, if not a very courageous one.

Yes, a lot has changed, but one thing hasn’t. That drop-off moment is just really hard.

Right after the final goodbye the daughter gently slipped an acorn into my hand. I’m glad I had already said all that I wanted to say. I couldn’t talk anymore.

Kent Hickey is president of Seattle Preparatory School.

Thanks for reading!  Dr. Lisa Lynn Sowder

i would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

 

Children, Highly Recommended Reading

Should I have my Biocell textured breast implants removed???

June 17th, 2019 — 11:50am

Looking pretty awesome after all these years.

This is a question posted by a patient on RealSelf.  She’s a lady in her 50’s with 11 year old anatomic Allergan Style 410 implants.  She has typical menopausal symptoms and does not think her implants are causing her night sweats, mild brain fog or hot flashes.  She’s heard about BIA-ALCL and wants to know if she should have her implants removed.  The photos she submitted show an absolutely beautiful long term result and the rest of her looks pretty awesome too.  She’s obviously either biologically privileged or she’s a gym rat or maybe both.  She’s very lean.  She doesn’t have enough fat for a meaningful fat transfer. Her breast volume is mostly implant. She loves her implants but she is scared.  What should she do?

So let’s be rational about the advice we give her based on what we know about BIA-ALCL.  First of all, she cares about her appearance.  Will she look good after explant?  IMHO, no.  She will be very, very small breasted.  If she’s okay with that, fine.  But I don’t think she will be okay with it.

What are the odds that she will get BIA-ALCL?  The latest numbers coming out of Dr. Mark Clemen’s work at MD Anderson estimate the chance of her developing BIA-ALCL is about 1 in 3000.  What about the chances of her DYING from BIA-ALCL?   Well, with increased awareness, early diagnosis and proper treatment, those chances are approaching ZERO.  I cannot rationally recommend she part ways with her awesome and great looking implants for those odds.

Now let’s look at breast cancer.  What are the odds?  Well, about 1 in 8 or 9 women will be diagnosed with breast cancer. The cure rate for breast cancer is much lower that the 90% plus cure rate for early diagnosed and properly treated BIA-ALCL.  Do we recommend bilateral prophylactic mastectomy for your average patient with average breast cancer odds?  Of course we don’t.  Women should be freaking out about the fact that they have breasts instead of the fact that they have textured breast implants!  And this post is in no way dismissing the suffering and, yes, death of patients with delayed diagnosis and/or treatment of BIA-ALCL.  These numbers mean nothing to someone who has died or lost a loved one BIA-ALCL.  We now know so much more about the etiology, diagnosis, prevention and treatment of this really weird malignancy.

So this is what I would advise this lady if she were my best friend or sister:  Her implants are getting up there in years.  I would get them removed and replaced with smooth, round cohesive gel implants.   With her anatomy she will look fine with round implants.  It’s been demonstrated very well that anatomic implants offer almost zero benefit over round implants in patients with normal anatomy.  If her surgeon finds seroma fluid or capsule nodules, he/she should do a capsulectomy and send the fluid and capsules for examination.  If the capsule is smooth and thin and unremarkable, he/she can just adjust the implant pocket if necessary to accommodate the new implant and leave the existing capsule in place.

And then she needs yearly exams and regular mammograms based on her breast cancer risk.

Thanks for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

Breast Implant Illness, Breast Implant Removal, Breast Implants

Opioid Free Surgery

May 20th, 2019 — 9:08am

I am very pleased to introduce our new opioid free surgery protocol.  This has been in the works for several months and we launched it 3 weeks ago with very good feedback from our patients.  Here’s just about everything you need to know.

Why?    The use and abuse of opioids cause a lot of problems not just for patient but society at large.  On the patient level, opioids often cause side effects such as itching, nausea, constipation, fuzzy head, bad dreams and the list goes on.  Having been on opioids myself for various surgical procedures, I personally think they don’t do a very good job at controlling pain but just get you so fuzzy in the head that you just don’t care.   On a societal level, have you heard of the opioid crisis?  The fewer pills out there in people’s medicine cabinet will mean less abuse.

How?   By approaching anesthesia and post operative pain in a different way, pain control can actually be better than what we have achieved in the past with opioids.  The non-opioid medications are started pre-operatively to provide a preemptive strike against the pain cycle.

What?  Here are the medications we use.  Acetaminophen a.k.a. Tylenol:  It’s good for head aches and post op pain.  Celecoxib a.k.a. Celebrex:  this is a non-steroid anti-inflammatory but does not have the blood thinning effects of other NSAIDs such as ibuprofen.  Inflammation is a major factor in pain.  Gabapentin a.k.a. Neurotin:  This is a medication used commonly for nerve pain.  It has a mild sedating effect in some individuals but does not fuzz your head nearly as much as an opioid.  Marcaine and/or Exparel:  These are long acting local anesthetics that are injected into the operative sites that can render the injected area numb for hours or days.  Ice: Oh, yeah, ice packs can help a lot.  My husband got through a gnarly knee operation with virtually nothing more than Tylenol and a gizmo that surrounded his knee with ice slush, provided by his awesome caregiver (that would be me).

When?  We have out patients take a dose of Tylenol, Celebrex and Gabapentin a couple of hours before surgery with a sip of water.  During surgery, the surgeon injects the operative area with local anesthetic.  After surgery, the patient continues with the medication combination.  Ice packs can be added for most types of surgery but check with us first.

Who?  All of us – surgeons, anesthesiologist, nurses, patients and their caregivers.  This protocol requires that we all work together.  The patients must make sure to take their medication before surgery, anesthesia must minimize or eliminate the use of opioids during surgery, the surgeon must be thorough with injection of the local anesthetics, the nurses must be sure the patients and their caregivers understand the pre and post-operative instructions.

So, how’s it working?  So far I have had a dozen patients on this protocol including a tummy tuck patient with very, very favorable results. I am very excited about this plan.  I’m sure we will tweak it here and there a bit but thus far I’m a total fan.

Thanks for reading and I would be honored if you followed me on Instagram @sowdermd and @ breastimplantsanity.

Dr. Lisa Lynn Sowder

 

 

Uncategorized

En Bloc Resection of Breast Implants and Capsules

April 2nd, 2019 — 9:20am

I get a lot of requests from breast implant illness patients to do an en bloc resection of their implants and the surrounding implant capsule.  The term en bloc refers to a procedure that removes the structure in question in one piece or all together.  This term is used most commonly in cancer surgery where a tumor is removed in its entirety without actually cutting into the tumor itself.  Except in cases of BIA-ALCL, implant capsules are not cancer.

The photo below shows an en bloc resection of two ruptured breast implants and the surrounding capsule.  In cases like this, doing an en bloc makes a lot of sense in that it prevents any spillage of silicone and makes for a much cleaner explant.  Fortunately it is cases like this where an en bloc is usually doable.  The thick, nasty and calcified capsule often just peels away from the adjacent breast tissue, muscle and chest wall without causing any collateral damage.  Doing a clean and slick case like this is what surgeons live for and believe me, I wish every explant would go just like this!

But……….it is not always possible to do an en bloc resection.   Sometimes the capsule is very, very thin and fragile (sort of like a wet Kleenex) and it is not possible remove it unbroken.  Sometimes the capsule is very adherent to adjacent structures such as breast tissue, ribs and chest muscle.  It is just not worth the damage to those normal structures to get an en bloc resection.  Sometimes, with implants under the muscle, the patient is at risk for a collapsed lung when trying to peel a very adherent capsule from the rib cage. In cases like this, the capsule can be removed with curettage.  And sometimes, with really large implants or those put in though the axilla (arm pit), the upper part of the capsule cannot be visualized with the implant in the way.  And if I cannot see it, I will not cut it.  In those cases, I remove the implant and then am able to safely remove the capsule.  I am very careful about minimizing or, in most cases, eliminating spillage of any leaking gel.bessss

 

I am aware that the breast implant illness community is obsessed with en bloc capsulectomy.  I’m not sure why because for clean, intact implants, there is no compelling reason to do an en bloc, except maybe to show off and promote oneself, and yes, I am guilty of that!   Many patients are lead to believe that there is some sort of evil humor or miasma that exists in the space between the intact and clean implant and capsule.  The space (which is actually what we call a potential space because it contains nothing) contains nothing!

It is really easy to pontificate for a potentially dangerous procedure when one has zero responsibility for any downside.  Who is responsible for harm to the patient – the surgeon holding the sharp instruments or the social media pundit?

And I am also aware that there are surgeons out there who guarantee an en bloc, every implant, every time.  I honesty don’t know how they can.  I also provide a guarantee… I’ll do my best.

Thanks for reading!  Dr. Lisa Lynn Sowder

I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Breast Implant Illness, Breast Implant Removal, Breast Implants, Patient Safety, Plastic Surgery

What does this plastic surgeon really think about breast implants?

March 27th, 2019 — 3:59pm

On Monday I testified in front of the FDA General and Plastic and Surgery Devices Advisory Committee on breast implant safety.  I think I surprised a lot of people in the room when I stated that I wasn’t crazy about breast implants.  Let me clarify a bit.

For the flat chest woman who could be mistaken for a boy with gynecomastia or a pubescent girl, and who does not have enough available fat for fat transfer, breast implants can be beneficial. Ditto for women who have a significant breast asymmetry or tuberous breast deformity that cannot be significantly improved without implants.  And some women with a pear shape (big hips and thighs and a narrow chest and small breasts), implants can add balance and be very beneficial.  Also, for women who have experienced deflation after pregnancy and nursing or after major weight loss, breast implants can restore volume to an extent that fat transfer usually cannot.  For mastectomy patients who are not good candidates for autologous reconstruction, implant based reconstruction can restore a sense of wholeness.  For these patients, breast implants are very beneficial.  And really, some patients find implants to be life changing in a good way.  Don’t judge a woman’s desire for implants until you’ve gone bra shopping with her breasts. That’s the upside of breast implants and really, all aesthetic breast surgery.

This might not end well.

Now I would like to wander into territory that a male plastic surgeon could not go lest the sisterhood ask for his head.  I would like to discuss the concept of bimbofication.  There are many, many women with perfectly fine breasts (defined by me as a nice shape and a size proportionate with the rest of their body) who opt to go larger, sometimes much larger in order to produce a hyper-sexual look and persona.  And I think this is a bad idea. Bimbos have a very short shelf life and getting what one wants via this sort of manipulation of certain types of men is not a good game plan at any age and is not going to work after a certain age.  It just won’t.

I also think that breast implants have skewed the vision of the ideal.  It is not normal for lean women to have huge breasts.  Yes, it occasionally occurs in nature (and a lot of them come in for breast reduction!) but it is not the norm.  I do think that the tide is turning some.  I think a more natural look is becoming more fashionable and I, for one, am glad to see it.  And for those who think I make millions stuffing breast implants into unsuspecting victims: if implants disappeared tomorrow my bottom line would likely go up because of my interest and expertise and experience in non-implant based aesthetic breast surgery.

Are breast implants safe?  I think smooth shell implants are.  (Textured implants, on the other hand, are worrisome.)  Breast implants have been around since the 1960’s and have undergone many design changes and a lot of scrutiny.  Many of the studies looking at implant safety are sorely lacking in follow-up (that’s also another blog) and it should come as no surprise that inserting a large foreign body has a lot of implant related down sides – rupture, deflation, malposition, capsular contracture, etc.  And they are not life time devices and have to be removed and/or replaced eventually.  I recently did a permanent removal of a ladies fifth set!  Do I think breast implants cause systemic illness?  I think there may be a teeny,  tiny subset of women who are sensitive to the materials in implants.  But I think breast implants are safe for the vast majority of women who choose to have them.

Now would I let my mother have implants?  No, she passed away 2 years ago (at 97!).  She had a full and lovely set probably because she did not breast feed her three children (it wasn’t in fashion in the 1950’s).  How about my sister?  I don’t have one but one of my sisters-in-law had postmastectomy reconstruction with an expander followed by an implant and balancing breast reduction and she looks better than she did before breast cancer.  She is thrilled with her result.  And how about my daughter? She is heading off to college this fall and will be making many, many decisions about her life without my input.  Actually, she has been making most of her decisions for a while now.  This is just one of many decisions.  Fortunately this young lady has a healthy body image and zero bimbo tendencies.  Lucky me.

So there you have it.  Implants are beneficial for many, many women and for some they are not.  I’m just glad to live and work in a society that allows adults to make their own choices!  You should be too.

Thanks for reading and I would be honored if you followed me on Instagram @breastimplantsanity and @sowdermd.  Dr. Lisa Lynn Sowder

Breast Contouring, Breast Implants

Today is Match Day – Maybe the Most Important Day in the Life of a Doctor

March 15th, 2019 — 12:00pm

Seattle Plastic Surgeon goes back, way back to Match Day 1983.

I remember the excitement of MATCH DAY like it was yesterday.

Every March, fourth year medical students across the United States convene to receive and open a small white envelope that has a huge influence on their future.  The information contained in this white envelope is where they “matched” for post-graduate training.

The Match System works like this:  As a fourth year student, you apply to a dozen or so residency programs and if asked, go for an interviews at these programs.  Then you rank the programs in decending order of fabulous to surely miserable and everything in between.  And the residency directors rank all of the applicants in decending order of incredible to surely a disaster.  An all knowing computer takes these rankings and matches the applicants with the programs.  Supposedly, the applicants’ wish list has more weight than the residency programs’  but I bet that students are still advised NOT to list any program that makes them want to chew glass instead of go there.

This is a momentous day.  This Match determines where you will live and train for anywhere from 3 – 8 years, who will become your BFFs, often whom you will marry, where you will eventually live and how you will practice your specialty.  Every fourth year medical student wants a great residency experience both academically and socially.

Okay, enough about that and more about me.  I matched at my 2nd of 10 choices, the University of Utah and, as a skiier and a woman, was thrilled.  Of course Utah has the BEST SNOW ON EARTH and the University of Utah had a lot of women in their general surgery program, even back then.

I ended up spending 6 years in Salt Lake City, 5 years as a general surgery resident and 1 year working in the Intermountain Burn Unit.  My years there made a man out of me (even though I’m a girl).  I came away from Utah feeling I could handle just about anything that walked in through the emergency room door.  I also came away from Utah in fantastic physical condition (the altitude makes for a strong cardio-pulmonay system), with many, many lifelong friends and a deep love and appreciation for deep, dry powder snow and Mormons (really).

And then there was Match Day for plastic surgery.  Again I snagged my 2nd choice, the University of Cincinnati.  I loved the program and training but it was a bit of culture and climate shock for me.  I even took up golfing which was about the only outdoor activity available.  I learned to love fireflies, the Ohio River, badass thunderstorms, cicadas and the way the humidity turned my naturally wavy hair into a Brillo Pad.  I never learned to love Skyline Chile which involves spaghetti noodles and cinnamon.

And now I am living in my home state, Washington in my dream city, Seattle.  But I so cherish those years away.  They expanded my world view while giving me great surgical training and some interesting ex-boyfriends.

So I hope every fourth year student matches at one of their top ranked programs and  some 36 years hence, looks back on their residency program with as much fondness as I do.

Thanks for reading.  I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.    Dr. Lisa Lynn Sowder

Surgical Eductaion

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