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: Fat Injection


Brazilian Butt Lift – A Dire Warning.

July 19th, 2018 — 9:29am
This is an email I received last week.  I want to share it here.  Please pass it along to anyone who may be considering a Brazilian Butt Lift:

Not worth dying for.

URGENT WARNING TO SURGEONS
PERFORMING FAT GRAFTING TO THE BUTTOCKS
(Brazilian Butt Lift or “BBL”)
This urgent advisory is in response to the alarming number of deaths still occurring from the Brazilian Butt Lift (BBL).The Multi-Society Task Force for Safety in Gluteal Fat Grafting (ASAPS, ASPS, ISAPS, IFATS, ISPRES), representing board-certified plastic surgeons around the world, recently released a practice advisory). Additionally, the Task Force is conducting anatomic studies to develop specific technical safety guidelines.Since the release of the practice advisory, deaths from this procedure continue to be reported. The unusually high mortality rate from this cosmetic procedure is estimated to be as high as 1:3000, greater than any other cosmetic surgery.

The cause of mortality is uniformly fatal fat embolism due to fat entering the venous circulation associated with injury to the gluteal veins. In every patient who has died, at autopsy, fat was seen within the gluteal muscle.

In no case of death has fat been found only in the subcutaneous plane.

The Task Force has therefore concluded that: FAT SHOULD NEVER BE PLACED IN THE MUSCLE. FAT SHOULD ONLY BE PLACED IN THE SUBCUTANEOUS TISSUE.

If the desired outcome might require another procedure, then manage the patient’s expectations and discuss the possibility of staging (as often done with fat injections, hair transplants, etc.)

IT IS EASY TO UNINTENTIONALLY ENTER THE MUSCLE DURING SUBCUTANEOUS INJECTION.

Therefore, stay mentally focused, alert, and aware of the cannula tip at every moment; be vigilant about following the intended trajectory with each stroke and feel the cannula tip through the skin. Consider positioning that can favor superficial approaches, such as table jackknife. Use cannulas that are resistant to bending during injection and recognize that Luer connectors can loosen and bend during surgery.

The risk of death should be discussed in your informed consent process, along with alternative procedures (such as gluteal implants or autologous flap augmentation).

No published series of BBLs done with intramuscular injections is large enough to demonstrate it can be done without the risk of fat embolism.

The subcutaneous plane has not been linked to pulmonary fat embolism. Until and unless data emerges that intramuscular injections can be done safely, the subcutaneous plane should remain the standard.

Fat injected into the subcutaneous space cannot cross the superficial gluteal fascia and migrate into the muscle; therefore, any intramuscular fat found at autopsy can be concluded to be the result of injection into the muscle.

Surgeons wishing to continue performing this procedure should strictly adhere to these guidelines. The Task Force is actively performing anatomic studies. and more specific technical guidelines will be forthcoming. We need to dramatically improve patient safety with this procedure through careful technique, or reconsider whether the procedure should still be offered. Patient safety is the number one goal of board certified plastic surgeons across the globe.

Sincerely,

 

Dan Mills, MD
Gluteal Fat Grafting Task Force co-chair
J. Peter Rubin, MD
Gluteal Fat Grafting Task Force co-chair
Renato Saltz, MD
Gluteal Fat Grafting Task Force co-chair
Co-Chairs
Multi-Society Task Force for Safety in Gluteal Fat Grafting* The information in this Advisory Statement while setting forth the strong recommendations of the Task Force, should not be considered inclusive of all methods of properly performing buttock augmentation with fat transfer or as a statement of the standard of care or as a mandate to strictly follow the recommendations of the Task Force.This Advisory Statement is not intended to substitute for the independent professional judgment of the treating plastic surgeon nor for the individual variation among patients.The Members of the Multi-Society Task Force and the participating societies assume no responsibility or liability for injury arising out of any use of the information contained in this Advisory Statement.** The Inter-Society Gluteal Fat Grafting Task Force represents leading clinical plastic surgery societies, including the American Society of Plastic Surgeons (ASPS), the American Society for Aesthetic Plastic Surgery (ASAPS), and the International Society of Aesthetic Plastic Surgeons (ISAPS). Additionally, two scientific societies, the International Society of Plastic & Regenerative Surgeons (ISPRES) and the International Federation for Adipose Therapeutics and Science (IFATS) are represented and provide scientific support. The efforts of the Task Force build upon a foundation of important work by the Aesthetic Surgery Education and Research Foundation (ASERF), the American Society of Plastic Surgeons (ASPS) Regenerative Medicine Committee, and the International Society of Aesthetic Plastic Surgery (ISAPS) Patient Safety Committee. The Task Force is an unprecedented collaborative effort to address a major patient safety concern, investigate factors that lead to increased risk with gluteal fat grafting, perform scientific studies to improve safety, and educate plastic surgeons.

 

I have been a member of the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS) for many, many years and do not recall any advisory with the strong wording of this one.  I abandoned intramuscular injection a couple of years ago when the news of deaths from this procedure came trickling in.  I suspect all ASPS and ASAPS members will follow this advisory.  My concern is that many surgeons who do this procedure are not board certified plastic surgeons and therefore not eligible for ASPS and ASAPS membership.  I hope they get this message and change their techniques.  I have seen a few Instagram posts and videos of butts being pumped up to the max that make my head spin and my backside ache.  The only true way to put this dangerous procedure in the rear view mirror is for patients to stop asking for it.  There are docs (and non-docs) out there who will do just about anything if the patient is willing to take the risk.  That Kim Kardashian butt is not worth dying for!

Thanks for reading and please follow me on Instagram @sowdermd and @breastimplantsanity.  

Dr. Lisa Lynn Sowder

Body Contouring, Fat Injection, Patient Beware, Patient Safety

Happy Valentine’s Day – Pucker Up!

February 14th, 2017 — 7:00am

Seattle Plastic Surgeon loves doing subtle and artful lip augmentation with Hyaluronic Acid fillers. 

Are they real or plumped up with filler? It should be impossible to tell with a nice and artful lip augmentation.

I am always amazed at how much my practice has evolved after being in practice for over 20 years now.  

Back in 1991 when I first hung my shingle, lip enhancement was done with collagen injections or with a procedure where a strip of skin above and below the lip vermilion border was excised and the lips expanded out.  I wasn’t enthusiastic with either procedure.  The collagen was often lumpy and the excision procedure left a scar and sometimes a funny shape. 

Then along came fat transfer and I liked this much better in that it lasted, sometimes for years and years and years, and it looked and felt natural.  But is was unpredictable in that some patients had resorption of the fat over time and needed repeat procedures.  And the recovery from fat transfer is a couple of weeks looking like the love child of Mick Jagger and Angelina Joli. 

Then along came lip implants, Softform Implants, that worked okay in some patients but in others distorted the lips with smiling or puckering.

Then along came HA (hyaluronic acid fillers) and oh happy day.  These fillers make lip augmentation predictable, natural and easy on the patient because down time is in hours or days at most.  The longevity of the fillers varies from filler to filler and from patient to patient but most patients get a good 3 – 6 months.   And a relatively new filler, Volubella lasts a year or more. 

I used to kind of cringe when I would see “lip enhancement” on my schedule.  With the new HA fillers, I love seeing this on my schedule because I know the patient will likely be pleased and that always makes my day.

Thanks for reading!  Dr. Lisa Lynn Sowder

Facial Fillers, Fat Injection, Lip Enhancement and Augmentation, Non-invasive, Plastic Surgery, Uncategorized

Stem Cell Face Lift

April 10th, 2013 — 3:15pm

Seattle Plastic Surgeon discusses the promotion of stem cell face lifts by ethically challenged physicians.

Stem Cell Face Lift

Pssstttt …. I’ve got a Stem Cell Face Lift for sale.

Recently I have had several inquiries about “stem cell face lifts” and whether or not I perform them.  There must be someone out there promoting this as the latest and greatest fountain of youth.   That someone  is probably deceptively promoting him or herself as a plastic surgeon with a magic wand.

A little background on stem cells:  These are little baby cells that can differentiate into almost any adult tissue.  Research on stem cells is one of the hottest areas of biology and with good reason.  Figuring out how to turn on the right genes in a population of stem cells could lead to tissue and organ engineering and amazing advances in the treatment of human disease and injury.

Adult fat tissue has a lot of stem cells.  Cool, huh?  Who would have thought that Mother Nature would pack away these tiny powerhouses of potential in our blubber?  Stem cells can be isolated from fat tissue in the laboratory using very sophisticated equipment .  This equipment  is not something available to physicians working in a clinical setting.   Stem cells are not being isolated from fat and injected into human faces.

So what’s the deal? Fat transfer for facial rejuvenation has been around for 20 + years and is becoming more and more popular as we understand the aging process better and also get better with the very fussy techniques required for successful fat transfer.  I’ve been doing fat transfer for facial rejuvenation for 15 years.  Fat transfer does something that is very obvious:  it plumps up a deflated face and makes it more youthful appearing.  It also does something else that has been observed by those of us who do fat transfer:  it improves the quality of the overlying skin.  And this qualitative improvement is likely the effect of stem cells that come along for the ride with the fat.  So the “stem cell face lift” practitioners are doing fat transfer but are promoting it as something new and unique.   It’s a little like calling a jelly donut a new type of fruit serving.

Check out this article in the New York Times. 

Thanks for reading and if you find a jelly donut that really is a fruit serving, please let me know.  Dr. Lisa Lynn Sowder

Facial Fillers, Facial Rejuvenation, Fat Injection, Uncategorized

POST ACNE SKIN REHABILITATION: A LONG AND INVOLVED PROCESS

March 14th, 2012 — 11:36pm

Do you have a child with severe acne???  An ounce of treatment now is worth a ton of scar revisions later.

Left: Before a bazillion procedures. Right: After a bazillion procedures.

I have two children in high school and I often am asked for advice regarding acne.  I am not a dermatologist nor do I play one on T.V. so do not expect any advice as to the latest therapies for acne.  I do have advice, however, on whether or not one should seek therapy.   So here goes.

If the zits are small and superficial, there will likely be no lasting damage and whether or not to seek anything other than over-the-counter treatment is really a matter of how much the zits bother your child.  BUT if the zits are deep (so called cystic acne), your child needs to get treatment YESTERDAY. 

 The problem with cystic acne is that it causes inflammation deep under the skin and can result in very bad scarring that can be devastating and permanent.   And it’s not just the scarring that is an issue.  The inflammation can also cause atrophy of the fatty layer under the skin and cause sinking in of the face. 

 The example on the right shows both superficial scarring and also some deeper scarring and atrophy.  This is a mild case.  If this were a man, he probably would not have sought treatment but this is a young, beautiful, fine featured woman and this post acne scarring affects her self esteem and also results in her spending a lot of time every morning trying to cover this up.   

She an I got to know each other very, very well over about two years of procedures that included fat grafting, skin resurfacing, excisional scar revision and filler injection.  It was a long process but worth it for both of us.  She can now get on with her day without the prolonged fussing with cover-up and I just loved the bright smile on her face at her last visit. 

 Not all plastic surgeons are well suited to treat these patients because it involves a lot of patience (which I for some reason have in abundance) and a lot of hand holding. 

 But the real message here is that if you know someone with deep, cystic acne who is not under the care of a dermatologist, do what you can to get them proper care.  What seems like just a minor, cosmetic issue can be a major, difficult to treat problem later. 

Thanks for reading!  Dr. Lisa Lynn Sowder

Acne, Children, Facial Fillers, Fat Injection, Plastic Surgery, Scar, Skin Care

“Hand Lift” – What a BAD Idea

December 13th, 2011 — 10:33pm

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

 

Aging Issues, Fat Injection, Hand Surgery, New Technology, Now That's a Little Weird, Now That's Cool, Plastic Surgery

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