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

Fillers that I don’t like. I hope they don’t take it personally.

September 21st, 2017 — 2:10pm

Seattle Plastic Surgeon blogs about fillers she does not like and does not use.  

I’ve written many blogs on the miracles of fillers for facial aging.  I think they are the best thing for facial maintenance since sunscreen.

Facial silicone gone bad. Really, really bad.

Facial silicone gone bad. Really, really bad.

The fillers I really like and use a lot are Voluma, Juvederm, Restylane, and Perlane which are all hyaluronic acid (HA) fillers.   The thing I love about HA fillers is their ease of use, safety, and their reversibility when a rare patient (1 every five years or so) does not like the result.  The HA fillers can be reversed by injecting an enzyme which dissolves the filler within 24 hours.

I also use fat as a facial filler in some cases. The thing I like about fat is that there is usually an abundant supply and it is often very, very long lasting and sometimes permanent.

There are other fillers out there.  Here’s my list of fillers that I just don’t like or use.  Full disclosure here:  this is based solely on my (sometimes very limited) experience, hearsay, prejudice and my risk adverse nature.  Some of my colleagues use these regularly and successfully but these fillers just give me the creeps.

  • Collagen:  It is sooooo yesteryear.  Even when it was the only legit filler out there, I didn’t like it.  Patients needed a skin test 30 days prior to using Collagen.  The results were fleeting and even a detail freak like me had trouble getting a nice smooth result.  Oh, it also had to be refrigerated and shelf life was very limited.  Oh, one more thing, it comes from cows.
  • Radiesse:  This is used quite a bit in the Seattle area but it gives me the creeps.  It’s made of teeny, tiny spheres of calcium hydroxylapatite and provides a scaffold for connective tissue growth.   It is quite thick and can fill in deep creases nicely but can also result in nodule formation.  Radiesse lasts 1 -2 years which is great (unless you are one of the unlucky ones who develops nodules).   I used it a few times years ago in a a few  employees who volunteered (really, they did) to be my training subjects.  All three of them bruised really, really badly and I felt like a worm until their bruising resolved.   I don’t have a cajones to try it again.
  • ArteFill:  Yikes.  This is a scary one.  This is a permanent filler which is made up of teeny, tiny spheres of polymethylmethacrylate.  They elicit a “foreign body response” which walls off the little spheres with collagen.   It also requires a skin test 30 days before injection because the sphere are carried in liquid collagen.  My training subjects this time were two pals of mine.  Both had negative skin tests.  My first patient did fine and is still my pal.  The second patient, who was from out of state,  had to delay her injection because a family illness prevented her from traveling.  Four months later, she had a rip-roaring inflammatory reaction to the little spot on her forearm where I had injected the test dose.  It was by the grace of a good and loving God I had not injected her face.  She is still one of my very best pals.  I have also seen many case reports and a couple of patients with poor results from ArteFill.  The only way to get rid of it is to surgically remove it.
  • Sculptra:  Sculptra stimulates dermal fibrosis and thickens the skin.   This is filler was first introduced about 10 years ago for use in patients with HIV.  The medications that many HIV patients rely upon to stay healthy have the side effect of facial wasting.  This filler is made of poly-L-lactic acid, the same chemical that a common suture, Vicryl, is made of.  I use Vicryl a lot.  It is easy to sew with.  It provides strength and support for a couple of months while an incision heals and then the body absorbs sit.  But once in awhile, a patient has an inflammatory reaction to the suture.  I have had maybe a dozen patients over 20 + years of practice who have “spit” every single stitch.  There are many case reports of disfiguring inflammatory reactions to Sculptra and all I have to do is think of one of my Vicryl “allergic” patients and I break out into a cold sweat.  Am I a wimp or what?
  • Silicone:  This is the Queen Mother of Bad Fillers (in my humble opinion).  It has been used for decades and is responsible for the permanent disfiguration of many, many patients.  I will never forget a lecture I attended when I was a surgery resident on the treatment of a bizarre condition called Romberg’s disease.  This disease causes profound atrophy of facial fat.  Way back when, these patients were injected with medical grade silicone and initially it was beneficial.  But fast forward 10, 20 even 30 years and many of these patients went on to develop severe inflammatory reactions that were more disfiguring than the original disease.  I know of a plastic surgeon in Hawaii who used this stuff on his wife’s lips.  Yikes.

So there is my personal rogue gallery of “no thanks” fillers.  All of these (I think) are still in the good graces of the F.D.A. but you won’t find them on my shelf.

Hey, thanks for reading.  That was a slog, wasn’t it?  Dr. Lisa Lynn Sowder

 

 

Facial Fillers, Fat Injection

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

Why fat transfer to the breast takes a lot of time and a lot of patience.

May 7th, 2013 — 11:32am

Fat transfer to the breast by Seattle Plastic Surgeon takes time and patience.

Fat transfer to the breast doesn’t seem like it would be a time consuming procedure but it is if done properly.    Here is what’s important and why fat transfer takes time and patience:

Patience - one of my few virtues.

Patience – one of my few virtues.

  •  The fat must be harvested very gently at a low vacuum.  This is a much slower process than regular liposuction.
  • The fat is often harvested from the posterior hip and buttock and lateral thigh area with the patient prone.  This means that a position change is necessary and that also takes time.
  • The fat must be handled with great care when it is transferred into injection syringes.  It’s important to have a patient and detail oriented assistant.
  • The fat must be injected in small aliquots into the breast, making sure to inject into several different layers.   This tedious technique pays off in the long run because it gives the fat a much better chance of survival compared to injecting big blobs of fat that probably won’t survive.  It has to do with blood supply.  That’s another blog topic.
  • The areas of injection vary with the shape of the breast.  When doing an augmentation with an implant, there is very little control of the breast shape but with fat transfer, the shape of the breast can be altered.  This also takes time and multiple visual assessments with the patient sitting up.

Some surgeons do not have the temperament to do procedures as tedious as fat transfer to the breast.  But I do!

Thanks for reading.  Dr. Lisa Lynn Sowder

 

Breast Contouring, Fat Injection, Fat Transfer to the Breast

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

Face Lift, Facial Fillers, Fat Injection, Uncategorized

Nice result with fat transfer in an older patient.

October 5th, 2012 — 3:21pm

Fat transfer to the breast is looking like a great operation to this Seattle Pastic Surgeon.

Before (left) and after (right) fat transfer to the breast in a 60 year old jazz vocalist.

 

Here is yet another satisfied fat transfer to the breast patient.  I slimmed down her muffin top and added some fat to her breasts.  She went up one cup size and also got a bit of a lift, not only in her bustline but also in her spirit! 

Her recovery was quick.  She was back to all her normal activities in about 3 weeks.

It has been sooooo rewarding doing this new procedure for the past year and a half and seeing what a difference it can make in selected patients. 

Thanks for reading.  Dr. Lisa Lynn Sowder

Breast Contouring, Breast Lift, Fat Injection, Fat Transfer to the Breast, New Technology

More good news about fat transfer to the breast.

June 14th, 2012 — 4:56pm

Seattle Plastic Surgeon finds that fat transfer to the breasts allows for subtle improvements in breast shape.

Before fat transfer

 

After fat transfer

      The more cases of fat transfer to the breast I do, the more I appreciate some of the advantages of fat transfer over breast implants.  There are the obvious advantages of no cost or upkeep of implants, no need for anything other than teen tiny incisions and the improvement in the shape of the fat donor sites.    

       Another advantage that is nicely shown in these photos, is the ability to subtly improve the shape of the breast.  This is possible because specific areas of the breast can be targeted for injection.  In this case, before fat transfer, the bottom of the breasts was quite square.  After fat transfer, the bottom is more rounded.  Also, the fat filled up the upper part of her breasts.  I think I hit a home run on the right side.  She may be coming back for a little more to get that left side looking as good as the right. 

        After 20+ years in practice, it has been so exciting and enjoyable learning this new procedure and being able to offer it to selected patients. 

Thanks for reading!  Dr. Lisa Lynn Sowder

Breast Contouring, Fat Injection, New Technology, Patient Safety

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

Fat transfer to the breast – I’m getting enthusiastic.

March 8th, 2012 — 12:26am

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

Breast Contouring, Fat Injection, New Technology, Now That's Cool, Plastic Surgery

Agressive Skin Care + Enough Filler = GREAT RESULTS

December 14th, 2011 — 10:25pm

Seattle Plastic Surgeon shows off a GREAT NON-SURGICAL RESULT – take a look at this.

Seattle Plastic Surgeon, Facial filler, skin careTop photo before treatment. After photo is after agressive skin care and HA filler over a nine month period.

I saw this patient recently who I have been treating with aggressive skin care and HA fillers (eg Restylane, Juvederm, Perlane, Prevelle) over about 9 months.  She has been very, very dedicated to her skin care program and I’ve been very, very dedicated to injecting her with filler where she needs it and, as mentioned in a previous blog, using enough to really filler ‘er up. 

And take a look at these photos.  Her skin quality is so much better and the shape of her jaw line and chin is so improved and her wrinkles —- what wrinkles?????  

Fat transfer followed by a deep chemical peel could have achieved this result but no face lift, I repeat, no face lift could have achieved this sort of improvement.

 Yes, she will need continued skin care and will need to come in every year or so for some more filler but remember, this is all with no down time and very, very little pain and suffering. 

 And just remember all of those things we do that also need maintenance – hair, nails, legs, bikini line (ouch),  eyebrows, etc.  Oh yeah, and how about getting your teeth cleaned every 6 months.  No down time but talk about pain and suffering! 

Thanks for reading!  Dr. Lisa Lynn Sowder

Aging Issues, Dental Issues, Face Lift, Facial Fillers, Fat Injection, Jawline, Nasolabial Folds, Non-invasive, Plastic Surgery, Skin Care

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