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

Category: Breast Contouring

Nipple reduction and a breast lift can make the breasts look fuller.

September 27th, 2017 — 11:55am

Check out this case.

This lady initially came in for breast augmentation.  She wanted to look a little fuller but was a worried about the impact of larger breasts on her competitive tennis game.  After chatting with her and examining her, I came up with the plan of a lift and a nipple reduction.  These procedures would give the illusion of fuller breasts without actually increasing the volume.

A small and saggy breast with a long stretched-out nipple looks – I’m gonna say it – a little pathetic.  Once the breast skin is tightened up and the nipple shortened, the breast looks almost the way it did before babies, breast feeding, gravity, general aging, etc.  And a procedure like this is maintenance free.  It should last a lifetime.  But remember to wear a bra most of the time when upright.  Gravity never sleeps.

Thanks for reading!  Dr. Lisa Lynn Sowder

Follow me on Instagram @sowdermd and @breastimplantsanity.

Breast Contouring, Breast Lift, Mommy Makeover, Nipples

Anatomical versus Round Implants: The study that could never be done was done.

August 4th, 2017 — 10:57am

Can’t tell which side is anatomic and which side is round? Neither can I!

I think the anatomic implants vs. round implants smack down may finally be over.  As those who read my blog know, I am not a huge fan of anatomic implants although I have tried really, really hard to learn to love them over many, many years.  Anatomic implants are presented as the best thing since microwave nachos and those of us who keep going back to round implants are sometimes dismissed as Luddites.  Anatomic implants are pushed by industry paid “experts” who make the rounds at meetings and extol the wonder of these more-expensive-and-more-complicated-than-round implants.  And patients ask for these anatomic implants being lead to believe that they will look more natural.  

A few years ago, evidence started trickling in that anatomic implants actually did not have  advantages over round implants in standard breast augmentation in anatomically normal women. There were studies where before and after photos were shown to expert plastic surgeons and they could not tell which patients had which implants.  I was present at one of these sessions where a panel of experts did no better than a coin toss.  But the study that nobody thought could be done – put an anatomic in one side and a round in the other side on the same patient – has been done!  No patient would sign up for having two differently shaped implants used for her augmentation and no institutional review board would approve such a study.  But some very clever surgeons did this study in 75 volunteers.   Their average age was 39 and their average BMI was 20 (this, by the way, is quite thin).  The surgeons took the patients to the OR and put a round implant in one side and a comparably sized anatomic implant in the other side and then took standardized photographs.  They then removed the anatomic implant and replaced it with a round implant to match the other side.  The standardized photographs were shown to a panel of experts.  Even the panel of experts could not tell the round vs. the anatomic when presented with these side by side breast implants!

I really take my hat off to the Drs. Hidalgo and Weinstein for doing this study.  It is this sort of research that helps us make decisions based on reality rather than the latest hype from an industry hired gun.  

Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation:  A Randomized Controlled Trial.  Hidalgo, David A. M.D.: Weinstein, Andrew L. M.S., Plastic & Reconstructive Surgery:  March 2017, Pages 587-596.

Thanks for reading!  Dr. Lisa Lynn Sowder



Breast Contouring, Breast Implants, New Technology

Clinical research is really, really difficult!

June 19th, 2017 — 6:19pm

That’s a lot of paper work!

I was doing some office spring cleaning the other day and came across two file boxes of patient charts from a breast implant study I participated in years ago. The study was the McGahn Silicone Breast Implant Adjuvant Study which was being conducted to gather information about the efficacy and safety of silicone gel breast implants which had been taken off the market in the early 1990’s. I enrolled 56 patients over about 9 years and had a study completion rate of about 80%. I remember how difficult it was to get patients to come in for follow-up although that was part of the agreement in order for a patient to participate. The follow-up was free but it still took phone calls, letters, e-mails and a little begging to get some patients to come in. During this study one of the new implants, the 153 anatomic gel, was found to have a very high early rupture rate and was quickly taken off the market. I had several patients with this implant that required removal and replacement but I had no other serious adverse events. I was happy to participate in this study even though it was a ton of work for me, my patients and my staff. It was many, many surgeons participating in studies such as this that lead to the new generation of gel implants being put back on the market and made available to patients for breast enhancement or reconstruction. Some groups that are pushing to have breast implants banned have criticized these clinic studies and have pointed out the less than perfect follow-up. I cannot speak for other study participants but we worked very, very hard to get our follow up number. I think that the difficulty of clinic studies is not appreciated by those who have not participated either as investigators or patients. And the think most of the lay public is clueless on this topic. I have done a lot of research in my career, mostly lab research in college, medical school and residency and mostly clinical in practice and I can say that I think lab research is a lot easier!

Thanks for reading! Dr. Lisa Lynn Sowder
Follow me on Instagram @sowdermd and@breastimplantsanity

Breast Contouring, Breast Implant Removal, Breast Implants


May 14th, 2017 — 7:00pm

motherhoodSeattle Plastic Surgeon Discusses Mommy Makeover on Mother’s Day

Ah, the joys of motherhood! I can wax eloquently about fat little feet, apple cheeks, wet baby kisses and so on but one of the joys I did not expect was a boost in my Plastic Surgery practice, especially my “mommy makeover” patients. Since becoming a mother myself, I speak “mommy” really well. I know first hand the glorious details of feeding, bathing, changing, and schlepping the baby. I can recite the stages of the toddler, the preschooler, the gradeschooler, the tween, the teenager and currently I am becoming an expert on the joys of being the mother of young adults.  

Being familiar with all that being a mother requires makes me much better at counseling patients about the process and timing of a “mommy makeover”.

“Mommy makeovers” usually combine breast surgery (augmentation and/or lift or reduction) with body surgery (usually abdominoplasty and/or liposuction). Most women are healthy enough to have a combination of procedures during one operative session. It is, however, the first couple of post operative weeks that are the most challenging for the patient.

Mommy is used to taking care of everyone but herself. After surgery the Mommy needs to take of only herself. She needs to be “Queen for a Week or Two” and resist the urge to cook, clean, change, wipe, mop, vacuum, load, unload, fold, etc. And if her youngest weighs over 20 pounds, she may not pick him/her up for at least two weeks if breast surgery was done and for at least six weeks if an abdominoplasty was done. The little one can crawl into Mommy’s lap for a cuddle but NO HEAVY LIFTING for Mommy. This also applies to the dog.

It’s very important to for patients to discuss these issues with their families. I’ve had a few ladies who have underestimated their recovery time, have done too much too soon and have turned what should be a relatively comfortable and relaxing recovery into a very sore and frustrating one.

So, calling all mothers interested in a “mommy makeover”: Plan ahead and get your husband and your children and your friends on board. Make a sign for your bedroom door. “DO NOT DISTURB – MOMMY RECOVERING”.

Body Contouring, Breast Contouring, Breast Implants, Breast Lift, Breast Reduction, Mommy Makeover, Plastic Surgery

I am pleased to offer Ideal Breast Implants

May 3rd, 2017 — 6:05am

Seattle Plastic Surgeon now offering the IDEAL IMPLANT.

I am happy to report that I am really, really liking The Ideal Implant.  And so are my patients.  This new type of saline breast implant crossed my radar screen late last year when I read an article in the New York Times about the implant and it’s inventor, Dr. Robert Hamas.  At the time the article was published, this implant was available only to those plastic surgeons who had invested in the company.  I felt a little left out!  But about a year ago the company expanded the availability of the implant to surgeons like me who are certified by the American Board of Plastic Surgery.

This implant is different from other saline implants in that it has internal baffles that dampen the sloshing around of the saline.  These baffles make the saline behave more like gooey gel.  When I felt this implant, it was a lot squishier and natural feeling than a standard saline implant.  I don’t think it was quite as squishy as a gel but it was really close.  And this implant really holds it shape.  It does not collapse and wrinkle like a saline implant does when held upright.Blog IDEAL IMPLANT

So I am pretty pumped about this new implant and I am totally in awe of Dr. Hamas who thought of this and actually pursued the idea and brought it to market.  Dr. Hamas joins my small pantheon of heroes who just don’t think of great stuff, they actually do great stuff.

Of course the question is why would a woman choose this implant over a silicone gel implant?  Aren’t gel implants awesome?  Aren’t they safe?  Gel implants are usually awesome but they can cause real problems if they leak or rupture.  I do not think gel implants cause systemic illness but a leaking or ruptured gel implant can make a pretty big mess of a breast.  I take out lots and lots of nasty old gel implants and have seen the damage they can do over the years.  In most cases, but not all, the breast can be made to look okay with a new implant and/or a breast lift and/or fat transfer.  And I have to add, the most common issue I see with breasts messed up by any type of implants is the fact that the implants were just too big for the chest in the first place.   Breast implants that are too big can cause big problems.

I also take out lots and lots of old deflated saline implants (I did two of these cases yesterday).  The saline implants usually don’t cause the same extent of inflammation, scarring and damage that gel implants do.  They just don’t.  Maybe this is because a patient with a leaking or ruptured saline implant knows she has a problem because her breast deflates and she gets it fixed in a timely fashion.  Contrast this with a leaking or ruptured gel implant that just sits there for years without any obvious change.  I’ve taken out implants that I would bet have been ruptured for decades.  Yes,  I know that an MRI will pick up a ruptured gel implant but it is a rare patient who dutifully goes in for her bi-yearly MRI as recommended by the FDA.

If you are interested in these implants, I can let you see and feel one.

Thanks for reading!  Dr. Lisa Lynn Sowder

To make an appointment, please call 206 467-1101.

Follow me on Instagram.  I have two accounts:  @sowdermd and @breastimplantsanity.  See you there!


Breast Contouring, Breast Implants, New Technology

Louis Pasteur and why you shouldn’t worry too much about mold or fungus in saline breast implants.

April 25th, 2017 — 9:49am

Louis Pasteur in his lab.

I have had a lot of questions lately about mold and fungus in saline implants. I have even read online that some people think intact sterile saline breast implants can somehow get filled with germs.  When I read stuff like that my thoughts go to the great French Scientist Louis Pasteur and your thoughts should too.   Pasteur contributed many, many great inventions and discoveries.  If you drink milk or wine, you can thank Pasteur for the safety of those two nourishing beverages.  If you and your children benefit from vaccinations, you can thank him for that too.  If you have pondered the deeper meaning of stereoisomers in your organic chemistry class, thank Louis.

But enough about that stuff and lets talk saline breast implants. One of Pasteur’s greatest contributions was the debunking of the myth of spontaneous generation.  You see, way back then before microscopes, microbes could not be seen.  When something would ferment or rot or putrefy or suppurate (I’m making myself a little sick), it was believed that the agent of this process just materialized from, well, nothing. The noxious effluvia that generated the aforementioned conditions was referred to as miasma.

In a series of really elegant experiments using some custom made glass vessels, Pasteur showed that a liquid rendered sterile by heating would remain sterile unless it came into contact with something that had not been sterilized.  The infectious agent had to exist in the environment.  It just did not spontaneously generate.  He figured all of this out before even seeing those nasty little germs under a microscope.  Very smart guy.

So what does this have to do with mold, fungus or bacteria in saline breast implants?  Every reasonable implant surgeon on the planet uses a closed system to fill an implant. The saline that goes into the implant comes from a bag of sterile saline for intravenous use into a sterile length of IV tubing and into the sterile implant.  The saline is never exposed to the air which can harbor spores and other creepy things we cannot see with the naked eye.  No contamination means the saline in the implants stays sterile.

What about the implant pocket?  We know that bacteria are present in cases of capsular contracture.  The current working theory of capsular contracture is that it is an inflammatory response caused by biofilm caused by certain types of bacteria.  One type of biofilm causing bacteria, Staph epidermis, is ubiquitous.  A conscientious surgeon does everything he/she can to help minimize the exposure to the implant to the environment, including the patient’s skin, prior to insertion.  Another type of bacteria could be one cause of the very creepy BIA-ALCL and again a conscientious surgeon will use techniques to minimize contamination.   So yes, we know the breast is not a perfectly sterile environment.  The more we learn about the microbiome that is us the more we realize that healthy people co-exists with a lot of “germs”.  If the presence of a microorganism meant illness, we would all be at death’s doorstep.  In fact, our mitochondria (tiny organelles in our cells that generate energy) are likely the descendants of bacteria that some single celled organism co-opted.  God, I love cell biology.  Don’t you?

What about saline implants that leak from a tear or from the fill valve?   Could microorganisms creep in there?  Yes they could but they will need something to eat.  Normal saline, which is used to fill saline implants has no energy source. Those microorganism are going to go pretty hungry.  I am aware that here are some really weird life forms that seem to exist in the most hostile and unnourishing environments – bubbling mud pots in Yellowstone, deep ocean sulfuric steam vents, etc – but me thinks that those critters aren’t going to show up in a beast implant.

I have taken out a bajillion old saline implants and, I swear on a stack of plastic surgeon journals, have never seen one that was contaminated with fungus.  I have seen a few with little floaters that I cannot explain.  When I’ve sent the saline in such implants, the cultures have come back no growth.  What does that mean?  I don’t know.  There I said it:  I don’t know.  Could a little speck of something floating around in an intact saline implant destroy a person’s health?.  I don’t know but it seems unlikely to me unless that little speck was Polonium-210.

I have had a quite a few breast implant illness patients who were absolutely bummed that their implants were not contaminated because they had become convinced that they were.  Yes, I have seen photos of really nasty and moldy implants out there in cyberspace and yes it is obvious that some implants are contaminated and that there are unreasonable surgeons who don’t used a closed system but I think those cases are rare. Nobody posts photos of old, pristine saline implants (except me on my Instagram @breastimplantsanity).  Pristine saline implants are boring.  And I promise, cross my heart, if I take out a nasty implant filled with fungus balls, I will let you know.

Soooo, if you think your implants are moldy, you could be but probably are not right.   But as anyone who knows my practice, I will take implants out for any reason.

Thanks for reading and you should read up on Louis Pasteur.  The contributions he made to science are nothing short of amazing.  Dr. Lisa Lynn Sowder

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

Breast Contouring, Breast Implant Illness, Breast Implant Removal, Breast Implants, Stuff I love

Shaped vs. Round Breast Implant Smackdown

April 20th, 2015 — 8:53am

Shaped vs. Round Breast Implants

blog panel of experts

Shaped or Round Breast Implant? Toss a coin!

Shaped breast implants are all the rage these days.  A lot of this is driven by the manufacturers who love to promote these implants and a lot is driven by patients who sometimes insist on the latest and greatest be it a cell phone, blender or breast implants.  And I use shaped implants from time to time but in many cases, a shaped implant is of no advantage over a round implant.

About a year ago, I attended the annual meeting of The American Society for Aesthetic Plastic Surgery (ASAPS).  One of the best presentations involved a panel of five well seasoned (a.k.a. over 50) plastic surgeons.  They were shown multiple before and after photos of breast implant patients and asked to comment on the cases, in particular whether the patient had shaped or round implants.  The panel of experts was right less than 50% of the time!  In other words, they could have had a panel of five year olds toss a coin and come up with better results!

Years ago I was quite enamored with shaped implants and actually came to rather despise them!  I had issues with malposition and particularly rotation which can lead to some funky shaped breasts and which requires re-operation.  I have gotten a whole lot better with these implants with improved implant design and modifying my technique, but honestly, in 90% of cases a round implant will work just fine as long as it’s NOT TOO BIG (that’s another blog).

So in most cases a patient can save themselves some money and me some aggravation by going with round implants.  Yet another win win.  I just love win win, don’t you?

Thanks for reading!  Dr. Lisa Lynn Sowder

Breast Contouring, Breast Implants

The Ideal Breast

November 6th, 2014 — 10:08am
blog ideal breast

The ideal breast has a little more fullness below the nipple and above the nipple.

The Ideal Breast

I just read an interesting review of an article published in the Journal of Plastic and Reconstructive Surgery about the ideal breast.   Here’s the link.

If you don’t want to read the review, I will summarize.  A bajillion individuals which included men and women of various ages and nationalities were asked to rate a series of breasts on their attractiveness.  The findings were interesting in that size was not as much of a factor as was the shape and proportion of the breast.  And – surprise!- the majority of judges preferred a breast that looked natural which translates into a breast that does not have a bulging upper pole.

I am just glowing after reading this article.   I have made it my life’s work to make breasts look like they could have occurred in nature on a really, really, really good day!

Thanks for reading!  Dr. Lisa Lynn Sowder


Breast Contouring, Breast Implant Removal, Breast Implants, Breast Lift

Will I be happy with fat transfer to the breast?

October 23rd, 2014 — 12:47pm

Check out these el cheapo breast enhancers.

blog fat transfer sizingThose of you familiar with my web site and this blog know that I really like to emphasize that fat transfer to the breasts is much different than a breast implant procedure.   Fat transfer results in a much more subtle and natural appearing enhancement compared to breast implants.   Here is a great way to determine, in the privacy of your own home,  if you will be happy with fat transfer.

There are a bajillion kinds of breast enhancers (we used to call them falsies when I was in high school) on the market.  I keep the June Tailor Beautiful You enhancers in two sizes in my office to help patients visualize that fat transfer can do.  These enhancers are available at Joanne Fabrics and they are very reasonably priced.  The larger size is pretty representative of the size increase a woman with a little breast laxity and  nice juicy donor sites (hips, tummy, thighs) can expect.  The smaller size is a pretty good idea of what a smaller, slimmer woman with tight breasts can expect.

So if you are thinking about fat transfer to the breasts, buy a pair of enhancers and wear them around for a few days.  And if you come in for a consultation, make sure to bring your enhancers with you.  That will give me a good idea of what sort of volume increase you will be happy with and help me determine if you are a good candidate for fat transfer to the breast.

Thanks for reading!  Dr. Lisa Lynn Sowder






Breast Contouring, Fat Transfer to the Breast

FAQ: Should I lose or gain weight before surgery?

October 21st, 2014 — 2:21pm

What’s the ideal weight for plastic surgery?

Which Oprah will do best with surgery? Probably the one in the red dress!

I get this question a lot from patients who are thinking about having breast and/or body contouring.  It’s an important question and I am always glad to hear it because it tells me that the patient understands that weight fluctuations can make a difference in surgical outcome.  Take Oprah for example.  There have been times in her life where her weight has yo-yoed all over the place.  Operating on her during these times would be like operating on a moving target.  A great result seen two weeks after surgery could turn into a lousy or even bizarre result a few months hence if her weight went up or down 30 – 40 pounds.

Sooo……patients should be at a stable and sustainable and healthy weight prior to surgery.  Did you notice that I did not say ideal?  Ideal weight may be achievable for some patients but unless it is sustainable, I would rather operate on a patient who is a little bit or even quite a bit over their ideal as long as they are healthy.

Healthy is the key word here.  If a patient is carrying a lot of excess weight and has type 2 diabetes, high blood pressure and has trouble walking up a flight of stairs, that person is not healthy and should not be having elective surgery.  That is the type of patient I will refer to a weight loss specialist.  If on the other hand, the patient is carrying extra weight and does not have diabetes, high blood pressure and plays an hour of pickle ball every day, I have no problem doing elective surgery on them.  And at the other end of the weight spectrum there are issues with being too thin.  I screen carefully for patients with eating disorders such as anorexia nervosa or bulimia.  Those conditions are serious illnesses and patients need evaluation, care and support – not plastic surgery.  Thin patients who are well nourished and weight stable usually make excellent surgical candidates.

So as you can see, it’s not about the number on the scale or the BMI or the dress size.  It’s about being healthy.

Thanks for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Breast Contouring, Obesity

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