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

Is it wrong to worship an operating room?

March 4th, 2014 — 10:53am

Seattle Plastic Surgeons does her first case in her new operating room.  It was a religious experience.

blog worship

Operating Room Worship: is it wrong?

Today I did three cases in our brand new operating room which is part of the brand new Madison Tower Surgery Center in Seattle.  And it was a great day.  Our new OR has plenty of space, natural light in addition to two powerful overhead lights, a new anesthesia machine and tons of storage space so that there is a place for everything and, so far, everything has been in its place.

Our old operating room was perfectly functional but was small and cramped and sometimes it felt like we were always bouncing off each other or a piece of equipment that didn’t really have a home.  And there were no windows which meant that a day in the operating room felt a little bit like working in a cave with good lighting.

Building out this new facility was a labor of love and money and I owe a lot to my associate Dr. Shahram Salemy for his vision and persistence in making it all happen.  It’s a great place to spend the day which is good because  I am going to be stepping up my schedule  to help pay for it!

Thanks for reading!  Dr. Lisa Lynn Sowder

My Plastic Surgery Philosophy, New Technology, Patient Safety

The Learning Curve

October 9th, 2013 — 2:24pm

Seattle Plastic Surgeon discusses the challenge of introducing new procedures to her practice.

The learning curve can be challenging for surgeon and patient.

The learning curve can be challenging for the surgeon and the patient.

This coming weekend thousands of Plastic Surgeons and their staff will decend on San Diego for the Annual Meeting of the American Society of Plastic Surgeons.  These meetings provide an opportunity to share ideas, techniques, new procedures, and new equipment and instruments.

Plastic surgeons tend to be very innovative and open to new ideas and it’s not unusual to come away from one of these meetings all fired up to try the latest and greatest.

Enter the learning curve:   With every new procedure or variation on a well established procedure, by definition someone has to be the first patient and that first patient may not get as good a result as the 10th or 100th or 1000th patient.  Or maybe the surgeon, after a handful of cases, decides that this latest and greatest is not really an improvement and he/she abandons it altogether.

Sometimes the learning curve is very favorable and sometimes it is so harsh that I am not willing to even give it a try.  An example of a favorable learning curve is transblepharoplasty browlift with Endotine fixation devices.  The anatomy was familiar.  The new instrumentation was eary to learn how to use.  Risk to the patient was low.  If it didn’t work, a conventional coronal brow lift could be done.  After about half a dozen cases, I got very good at selecting patients with favorable anatomy for this procedure and now do this procedure frequently.  Last year, after many, many patients, I had a failure of the fixation device on one side and had to redo that side.  That single device failure has not dampened my enthusiasm.

A procedure that I just can’t bring my self to try is a deep plane a.k.a. subperiosteal face lift.  This procedure was the latest rage 15 or 20 years ago.  It was supposed to give the most natural looking and longest lasting facelift results.  The downside is that the operative area is very close to where the facial nerves live.  These are the nerves that control facial movement.  A permanent injury to one of these nerves can be devestating.  Also, postoperative swelling can take up to a year to resolve.  There was a bit of a machismo aura attached to this procedure and maybe I just didn’t have large enough cajones to jump on this particular bandwagon.  The benefit of this operation, IMO, did not justify the risk to the patient.  And, these days, almost nobody talks about this procedure.  The buzz just isn’t there.

When I embark on a new procedure, I am very honest with my patients about my expereince or lack thereof.  I explain that it is a lot like cooking.  If a cook has good basic skills,  knowledge, and experience, making a new dish is not reinventing cooking, but rather applying those skills, knowlege and experience in a new way.

Thanks for reading!  Dr. Lisa Lynn Sowder


New Technology, Surgical Eductaion

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, 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 Transfer to the Breast, New Technology

A Surgical Cure for Type 2 Diabetes?

April 13th, 2012 — 2:23pm

Seattle Plastic Surgeon shares some great news about Type 2 Diabetes.

For years it has been observed that obese patients with Type 2 diabetes have a dramatic improvement in their diabetes after gastric bypass surgery.   And this improvement is seen almost immediately after surgery, long before the patient loses significant weight.  Now there is something more that just anecdotal reports of this finding.

Recently the results of a randomized, prospective study of 150 obese, type 2 diabetic patients treated with  surgery or intensive medical therapy was released.  This study was carried out at the Cleaveland Clinic and took a look at the blood sugars of patients one year after surgery vs. one year after intensive medical treatment. 

The surgery patients blew the medical patients out of the water with their blood sugars going down, way down, despite stopping their diabetes medications. 

This study confirms the many anecdotal reports of the past decade or so.  Could it be that the first line of treatment for this devastating disease that afflicts so many obese patients will be major surgery?   It’s too soon to tell but as these types of surgical weight-loss procedures become safer and safer, that just may end up being the case. 

Now we just need a fix for obesity that triggers most cases of Type 2 diabetes.    Send me your ideas for this.  I’d love to be in on it. 

Thanks for reading!  Dr. Lisa Lynn Sowder

General Health, New Technology, Now That's Cool, Obesity

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 Transfer to the Breast, New Technology

Strattice – is this my new best buddy in the operating room?

December 20th, 2011 — 11:23pm
Seattle Plastic Surgeon loves acellular dermal matrix, Strattice.

Strattice is very, very useful for difficult implant revision cases. It provides soft tissue coverage and position control for breast implants. It acts like an internal push-up bra. Sweet, huh?

Seattle Plastic Surgeon is really, really loving the acellular dermal matrix, Strattice.  So are her challenging breast implant revision patients.

In the past two months, I have been getting a lot of experience with Strattice, which is an acellular dermal matrix.  Sounds very complicated, huh? 

The concept is not complicated at all.  Strattice, which feels a lot like the chamois you may use to polish your car, acts like an internal bra.  It supports the breast implant the way a bra supports the breast.  It also provides some additional soft tissue coverage for the implant which is really nice in thin women.  And there’s more!  It appears that Strattice reduces the chance of the dreaded capsular contracture by altering the body’s scarring mechanism around the implant.   And there’s even more!  Strattice, which is made from pig skin, is eventually replaced by the patients collagen.  Like the term “acellular dermal matrix” implies, the Strattice acts as a scafold for the patients own tissue.  And yes, there’s even more!  Even though Strattice comes from pigs, none of my patients have sprouted  curly tails.

The downside?  Using Strattice is a little tricky and it adds O.R. and anesthesia time.  Also, it’s expensive but not as expensive as an additional breast implant revision.   

Time will tell if Strattice is really my new best buddy, but so far it’s looking very, very promising.  And, by the way, I get no, nada, zero, zilch $$$ for saying nice things about this or any other product. 

Thanks for reading.  Dr. Lisa Lynn Sowder

Breast Implants, New Technology, Now That's Cool, Plastic Surgery

“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

A blast from the past – the Polaroid photograph

October 27th, 2011 — 5:51pm

Seattle plastic surgeon, Dr. Lisa Lynn Sowder, fondly remembers her Polaroid camera.

This week I have seen a couple of patients whom I operated on way back in the early 1990’s.  We found their charts down in our storage room and in those charts were their Polaroid photos – a little faded but with pretty decent definition. 

Back in those days, I took two sets of photos: one with my Polaroid and then color slides with my Minolta SLR that weighed about as much as a Gorditos Burrito. 

About 15 years ago, I switched over to digital photography and a photo archiving system on my computer.  Storage and retrieval and duplication of photos is so much faster and easier. 

But the most beneficial effect of my new system is that it allows me to really scrutinize my before and after results. There is no waiting for the film to be developed and I don’t need a light box and my magnifying glasses.   Nowadays I see the results, right away, front and center and really big on my computer screen.  This sort of visual feed back is essential for plastic surgeon evolution.

I do miss my Polaroid a little bit.  It made for such a great party camera.  Does anyone else remember how fun it was to watch the picture develop? 

Thanks for reading!  Dr. Lisa Lynn Sowder

New Technology, Plastic Surgery

Fat Injection for Breast Enhancement – Too Good to be True?

May 17th, 2011 — 10:34pm

Breast enhancement with your own fat? Well, maybe.

Fat transfer to the breast:  Seattle Plastic Surgeon adds her two cents worth.

One of the hot topics at the annual meeting of the American Society for Aesthetic Plastic Surgery(ASAPS) in Boston which I attended last week was fat grafting to the breast. This procedure has a very interesting history.  Back when the earth was cooling and I was training to become a plastic surgeon (1983-1991), fat injections were considered fringe surgery and fat injections to the breast were for all practical purposes panned by the American Society of Plastic Surgeons (ASPS) and ASAPS.  Fat  injections to the breast were considered ineffective and dangerous. Well, that was then and this is now.

Fat grafting is now a well established procedure that has been used for facial rejuvenation, hand rejuvenation, the treatment of liposuction divots, buttock enlargement and a few other indications. Much of the early work done with fat grafting was performed by Dr. Richard Ellenbogen in L.A. and Dr. Sydney Coleman in New York and these two doctors were subject to ridicule and disbelief for several years. I remember in 1993, when I took my plastic surgery board exams, the correct answer to any question about fat grafting was that it didn’t work.   That is not the correct answer any more.

Fat grafting to the breast started with surgeons, myself included, using fat around the periphery of a reconstructed breast. For example, if there were contour defects at the edges of a breast reconstructed with an implant, some fat would be used to smooth that area out. Then we started using it for patients who had thin areas anound the breast following cosmetic breast augmentation.

Now we are using fat injected into the breast itself for breast enhancement. After taking several instructional classes on this topic in Boston, I am convinced that this is an appropriate and safe procedure for a very select group of  patients.

Fat injection, at least currently, will not acheive the same volume of enlargement that implants can.  Most fat injected breasts go up only one cup size. That eliminates a lot of ladies wanting to go a lot larger.  One of the doctors who spoke in Boston (and who has the most experience with cosmetic fat transfer to the breast) still uses implants in 90% of the patients who present to him for breast enhancement and uses fat in only 10%.

For the best results in patients with very tight breasts and chest tissue,  it is necessary for the patient to undergo breast expansion to stretch the breast and skin and to increase the breast vascularity prior to the fat transfer. This is done using a gigantic breast pump called the Brava System.

They should have called it the Brave System because it takes a brave lady to strap one of these babies on and then go out grocery shopping. The plastic surgeons who have the best results in thin, tight patients with fat grafting have their patients wear the Brava 10 hours a day for about 4 weeks. This is no small task. This Brava requirement also eliminates some patients wanting fat grafting. The experts (and who am I to question them?) tell these patients who want fat grafting “no Brava, no breasts”.

For patients who have experienced breast atrophy following breast feeding or weight loss, the tissues are loose and this preoperative stretching is not as important.  These patients will likely do okay without the Brava.

My week in Boston at the ASAPS meeting really opened my mind to this new way to enhance the breast and I am looking forward to offering this procedure to selected patients. But remember,  if you are “tight” – “no Brava, no breasts”.

Thanks for reading!  Dr. Lisa Lynn Sowder

Breast Contouring, Fat Transfer to the Breast, New Technology

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