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: New Technology


Maximizing Follow-Up in Cosmetic Surgery Clinical Trials – Money Helps

July 26th, 2018 — 9:05am

In a previous blog post bemoaning the difficulty of good follow-up in clinical research I sort of place most of the blame on patients who blow off the follow-up  once they have their desired implants.  This was my experience with the implant study I participated in many years ago.  I had an 80% follow-up at 5 years (which was really, really high)  mostly because I pestered patients relentlessly to come back for their follow-up exams.  I have taken a bit of flack (especially from the breast implant illness activists) for my blame-the-patient stance but now there is a recent study out that supports my politically incorrect opinion.  Check this out.  It seems if you pay the patient big bucks to show up they do!  This study has an astounding 94.9% and 96.7% follow-up compliance at 5 years.  The study has another 5 years to go and my guess is that given the size of the monetary award, those numbers will also be very high.

“Maybe I will show up for my follow-up.”

Novel Approach for Maximizing Follow-Up in Cosmetic Surgery Clinical Trials: The Ideal Implant Core Trial Experience

Mueller, Melissa A. M.D.; Nichter, Larry S. M.D.; Hamas, Robert S. M.D.

Plastic and Reconstructive Surgery: October 2017 – Volume 140 – Issue 4 – p 706–713
Cosmetic: Original Articles
Background: High follow-up rates are critical for robust research with minimal bias, and are particularly important for breast implant Core Studies seeking U.S. Food and Drug Administration approval. The Core Study for IDEAL IMPLANT, the most recently U.S. Food and Drug Administration–approved breast implant, used a novel incentive payment model to achieve higher follow-up rates than in previous breast implant trials.

Methods: At enrollment, $3500 was deposited into an independent, irrevocable trust for each of the 502 subjects and invested in a diversified portfolio. If a follow-up visit is missed, the subject is exited from the study and compensated for completed visits, but the remainder of her share of the funds stay in the trust. At the conclusion of the 10-year study, the trust will be divided among those subjects who completed all required follow-up visits. For primary and revision augmentation cohorts, the U.S. Food and Drug Administration published follow-up rates from Core Studies were compared for all currently available breast implants.

Results: Five-year follow-up rates for the IDEAL IMPLANT Core Study are higher for both primary augmentation and revision augmentation cohorts (94.9 percent and 96.7 percent, respectively) when compared to all other trials that have used U.S. Food and Drug Administration standardized follow-up reporting (MemoryShape, Allergan 410, and Sientra Core Studies).

Conclusions: This trial demonstrates the utility of a novel incentive strategy to maximize follow-up in cosmetic surgery patients. This strategy may benefit future cosmetic surgery trials and perhaps any prospective research trial by providing more complete data.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Hey, thanks for reading and I really thank Drs. Mueller, Nichter and Hamas for this awesome article.  And my hat is really off to Dr. Robert Hamas who not only thought up the idea of the Ideal implant but actually brought it to market.  And Ideal only sells its implants to surgeons certified by the American Board of Plastic Surgery.  That means if your surgeon is using an Ideal implant, he/she is actually a real honest to goodness plastic surgeon, not just poseur.

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

Breast Implant Illness, Breast Implants, New Technology, Now That's Cool

14-Point Plan for Breast Implant Placement

June 26th, 2018 — 1:53pm

Surgical techniques are constantly evolving and breast implant technique is no exception.  In the past couple of years recommendations to minimize implant and implant pocket contamination have been developed.  This is in response to overwhelming evidence that bacterial contamination is the main cause of capsular contracture and may also be the cause of breast implant associated anaplastic large cell lymphoma (BIA-ALCL).   Both of these conditions have been linked to the presence of biofilm around the breast implants.  Biofilm is the product of certain bacteria, Staph epidermidis in the case of capsular contracture and Ralstonia piketti in the case of BIA-ALCL.  It is our hope that with the adoption of the Surgical 14-Point Plan for Breast Implant Placement the annoying and difficult problem of capsular contracture and very serious and potentially fatal problem of BIA-ALCL will drop in frequency.  If you are planning on breast implant surgery, you should ask your surgeon if he/she uses the 14 point plan.  They should!

Surgical 14-Point Plan for Breast Implant Placement, from Aesthetic Surgery Journal, 2018, Vol38(6) page 625

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

Breast Implants, New Technology

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

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

Old Dog Learns a New Trick – Instagram

March 17th, 2015 — 1:52pm
blog stella

“I have more Instagram followers than my owner. Woof.”

Baby Boomer Plastic Surgeon Dives Head First Into Instagram

I just couldn’t take the nagging from my young staff any longer.  “Doctor Sowder, you just have to get onto Instagram.  That’s where everything is happening.”

So I finally did and I have to say there is a lot going on out there on Planet Instagram.  I have wasted many, many hours going down various Instagram rabbit holes.  I found all kinds of stuff and all kinds of people and I even found my own dog, Stella, who has many more followers than I do.

Check her out @ Stellathedog101 but then make sure you check me out too @ Sowdermd and follow me.  I want to tell her to “move over Rover”.

Thanks for reading!  Dr. Lisa Lynn Sowder

 

 

 

 

 

 

New Technology

One Year Later – Dunce No More!

July 21st, 2014 — 2:00pm

Seattle Plastic Surgeon celebrates her one year anniversary with her Electronic Medical Record.

blog EMR

I hate feeling like a dunce.

It was one year ago that our plastic surgery office “went live” with our Electronic Medical Record (EMR).  I had a fairly bad attitude towards EMR’s in general because the government was trying to push it down our throats, the exorbitant cost, and my experience with the EMR at Swedish Hospital (where I occasionally treat patients) was SUCH A DOG.  If I were called in after hours to stitch up a facial laceration in the ER at Swedish, I would spend one hour attending to the patient and an additional 2 hours trying to figure out how to document my care on their wretched EPIC system.

We spent a lot of time and energy and gnashing of teeth trying to choose and agree on the best EMR for us.  Then after making the decision, we had to pack up several briefcases with large bills to pay for it.  Oh and then, we had to totally re-do our servers which required another briefcase of large bills.  We had webinar training sessions and more gnashing to teeth and then on July 22, 2013, we went live.  I will never, ever forget that day.  We had two trainers in the office.  The patient load was pretty light and somehow I managed to keep up with the patient flow and the EMR documentation.  The hardest part, other than feeling like a dunce, was trying to wrap my pointy little head around the absence of a patient paper chart.  It just seemed so bizarre and I felt very insecure without that wad of paper called a patient chart in my hand.

A few months after live date, it was time to clear out old, obsolete patient charts.  I remember going through this whole wretched stack of paper charts and suffering  a very nasty paper cut on my right thumb.  Well, that did it.  I was finally ready to give up paper charts.

Our EMR  is by no means perfect and it has crashed pretty badly on one occasion.  But it sure beats the paper chase and those nasty paper cuts.

Thanks for reading!  Dr. Lisa Lynn Sowder

New Technology

The Revolution of Outpatient Surgery

June 20th, 2014 — 10:26am

Seattle Plastic Surgeon blogs about how much surgery has changed in just a few decades.

Sometimes it just astounds me how much surgery has changed since my days as a medical student.  There was a time when hernia patients spent  an entire week in the hospital following surgery.  They were admitted the night before, a bazillion lab tests were done, they got an enema after dinner and a sleeping pill before bedtime.  After surgery, they were given morphine injections, Jello and broth and bed baths.  Their incisions were checked everyday and after a week their stitches came out and they finally went home.  Fast forward to today and a hernia patient checks into an outpatient surgery center in the morning and by lunch time is home eating a ham sandwich and watching Breaking Bad reruns.  How did all of this happen in just over twenty to thrity years?blog AAAASF

Many of the changes have come about for economic reasons.  Keeping someone in the hospital for a week costs as much or more than a brand new Mini Cooper.  Insurance companies began to balk at these costs when I was a surgery resident in the 80’s.  I remember being shocked (shocked!) the first time some bozo from an insurance plan told me to discharge a hemorrhoid patient after just two days in the hospital.  I was used to waiting until those patients had managed to have their first bowel movement post op.  It was just, well, tradition.   So we started sending them home earlier and they did fine.  In fact, they did better than they if they were in the hospital being poked and prodded and woken up at midnight for vital signs.

Anesthesia has changed a lot too.  Back in the day, general anesthesia was almost guaranteed to leave a patient vomiting for a day or two after surgery.  These days, the anesthetic agents are much less nauseating and the anti-nausea medications much more effective.  And with spinal anesthesia, nausea is very rare.  I have not had to admit a patient to the hospital for nausea and vomiting and dehydration in at least ten years.

And surgical procedures have changed.  Take that hernia patient and his ham sandwich.  Thirty years ago he would have a six inch long incision in his groin and sutures tied so tightly that standing up straight would be difficult.  He would need a lot of narcotic pain meds which would make him nauseated.  He wouldn’t be able to keep the Jello down so he would need an intravenous line for a few more days.  He can’t go home until he can eat.  In contrast, these days the hernia is usually fixed from the inside out.  He has a couple of little incisions where the fiber optic scope was inserted to gently pull the hernia sac back into the abdomen when it belongs.  Then a plug of mesh is used to fill up the defect.  It’s slick and so much more gentle on the patient than fixing a hernia from the outside in.  Our patient is a little bit sore but will likely feel good enough to return to his desk job in a day or two, narcotic free.

So despite all the griping about our health care delivery system, it is actually getting better, more convenient and safer.   Now if someone could figure out how to make it less expensive.  But that’s another blog.

Thanks for reading!  Dr. Lisa Lynn Sowder

 

 

General Health, Government and Politics, New Technology, Postoperative Care, Preoperative Care

Breast Implants vs. Fat Transfer for Breast Enlargement

April 17th, 2014 — 3:41pm

Breast implants vs. fat transfer for breast enlargement.  Seattle Plastic Surgeon compares the two operations.

I have been doing fat transfer to the breast for about three years now.   When I started practice in 1991, fat transfer to the breast was dismissed as ineffective.  And indeed it was because the technique did not lend itself to long term viability of the fat.  These days, thanks to fat transfer pioneers like Dr. Sydney Coleman and Dr. Richard Ellenbogen, we know how to harvest, handle and inject the fat in such a way that most of the fat survives in its new location.   Fat transfer has become an important addition to my breast enhancement practice.  Based on my experience, here are the main differences between breast implants and fat transfer for breast enhancement.

2014-04-17 14.39.36

For most patients, there is a clear choice between these procedures but a few patients are really torn about which way to go.  In consultation, I provide as much information as I can about each procedure and make sure that patients understand the limitations of fat transfer and also the long term consequences of having breast implants.

Thanks for reading and check out my other blogs on fat transfer to the breast.

Dr. Lisa Lynn Sowder

Breast Contouring, Breast Implants, Fat Transfer to the Breast, New Technology

Breast Implant Capsular Contracture Revisited

March 27th, 2014 — 3:35pm

Sientra Textured Breast Implants may be an advance in the continuing battle against breast implant capsular contracture.

The breast implant business is a funny one.  Implants come and go and then come back again and then there’s something new that becomes old that is reconsidered or tweeked and then comes back into use and so it goes.  This is why the skeptical Dr. Sowder (that would be me) is skeptical.  But……….I think I might be onto something really, really new and improved in breast implant surgery.  And it’s sort of a new implant shell and gel design.

But the thing that is really, really new is that Sientra, the manufacturer of these implants, is putting their money where their mouth resides.  They are providing a two year warranty for their implants that develop a significant capsular contracture.  Until now, capsular contracture was never covered by warranties.

I recently attended a presentation regarding these newish implants and asked the CEO of the company how Sientra can possibly offer a warranty for a problem that has plagued breast implants from day one and is considered almost an act of God by those of us who do everything in our power to prevent capsular contracture.  blog sientra

Here is what may be different with implants manufactured by Sientra.

1.  Sientra textured implants have a different surface configuration that seems to allow more integration into the surrounding breast meaning that it does not scream “foreign body!” quite as loudly as a smooth implant or implants with other types of texturing.  It is the foreign body response that accounts for capsule formation.

2.  The Sientra implant cohesive gel is really, really adherent to the implant shell.  The shell cannot be torn off the gel.  The gel just sticks to the shell, even with strong traction.   So even if there is a tear or fracture in the shell, the shell and gel just hang together and the gel does not extrude outside the implant and possibly set up and inflammatory reaction leading to thickening or tightening of the implant capsule which is what causes capsular contracture.

3.  Sientra only sells its breast implants to surgeons who are certified by the American Board of Plastic Surgery, a.k.a. Real Meal Deal Plastic Surgeons (me, for example).  Sientra feels that those of us who have put in the years and years of training in plastic surgery do it better than those who have come to do cosmetic breast surgery via the back door.  This is not the case with the other two manufacturers of breast implants in the United States.

Sooooo…………. I am now offering Sientra implants for breast augmentation.  All the warranty paperwork is filled out by our office and every Sientra patient is automatically enrolled in the warranty program.  And if I never see another capsular contracture in my life…………….

Thanks for reading.  Oh, and Sientra doesn’t pay me to say nice things about them but they did feed me the other night at the dinner presentation but I only had one glass of wine and I skipped dessert.  Dr. Lisa Lynn Sowder

 

 

 

Breast Contouring, Breast Implants, New Technology

Voluma. I think I’m going to really, really like this new HA filler.

March 11th, 2014 — 1:32pm

Seattle Plastic Surgeon is happy to add Voluma to her toolbox.

Those who know me well know that I take a long hard look at new technology, products, procedures, etc.  I think that new is not enough.  It has to be better, safer, easier or less expensive that the technology, product or procedure it is gunning to replace.  I’m always so tickled when something new really does turn out to live up to its claims.

Seattle Voluma

My very brave first Voluma patient. Before injection on the left and after injection on the right. Note how her fuller cheekbones enhance her entire face. Oh, the eye makeup doesn’t hurt either.

Voluma is the new thing that floats my boat.  Here’s why.  Voluma is another hyaluronic acid (HA) filler, similar to other HA fillers such as Restylane, Juvederm, Prevelle, Perlane, etc.  What makes it different is that it was developed for deep injection onto the bone or in the fatty layer of the mid face.  Voluma allows for nonsurgical enhancement of the cheekbone area which in turn can improve the contour of the lower eyelids and also the nasolabial folds.

Other procedures that can enhance this area include fat transfer, cheek implants and vertical face lifts.  Of course, these all have down time whereas our Voluma patient on the left went to work about 10 minutes after her injection.  And she said it hardly hurt although maybe she was just being nice.

Voluma lasts about 2 years, much longer than the other HA fillers.

The cost for this new filler is twice that of the standard HA fillers but often less can be used because it is so “volumizing”.  A little bit goes a long way.

So this is another tool in my toolbox and one that I think I will pull out often.  Oh, and by the way, the makers or Voluma do not pay me to promote their product.  In fact, no one pays me anything to promote their products.  I prefer it that way and you should too!

Thanks for reading!  Dr. Lisa Lynn Sowder

 

Facial Fillers, New Technology, Stuff I love

Back to top