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

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Lessons Learned (and Confirmed) on my Rim to Rim Grand Canyon Backpacking Adventure

November 21st, 2021 — 5:55pm

I am still basking in the afterglow of last month’s Grand Canyon adventure.  Early in the pandemic, I came across an article on backpacking in Grand Canyon in one of the travel magazines my husband, Nick O’Connell, occasionally writes for. This article planted a little seed, or maybe a wild hair, in my head to do a 4 day/3-night backpacking trip down into the depths of Grand Canyon and then back out. Although I am an avid day hiker, I had not backpacked since college so this was a stretch for me at the ripe age of 65.  Floating this idea to my family, I soon had two enthusiastic partners in this adventure, my husband and one of our sons, Daniel.

Me with my husband and son soon after our arrival on the South Rim of Grand Canyon.

Although my husband is an experienced outdoorsman, I pushed to use a guide mainly to get a permit (not an easy thing), arrange transportation from Flagstaff (another not so easy thing), plan the food (no thanks) and hopefully maintain marital and familial harmony (it did).  We went with Wildland Trekking out of Flagstaff.

Within days of making a deposit the emails started arriving about preparing for this adventure. There was no sugar coating. Training for this was essential if the experienced was to be enjoyed rather than just endured.  About 4 months before our trip, right after I retired, I started training in earnest.  This involved a lot of walking up and down the hills of Seattle with a pack that started at about 5 pounds and increased to 30 pounds as I got stronger. (My training was curtailed for a few weeks following a harrowing car accident – not my fault! – which left my beloved stick shift purple Mini Cooper totaled and me bruised and sore from the airbag and seat belt.  That’s another blog.  Stay tuned.)  Nick and I also did at least one hike a week in the Cascade mountains near Seattle with full packs.  I also upped my weight training and yoga, drank protein supplements and slimmed down about 5 pounds.

We arrived at the North Rim and being a sea level dweller, I felt the altitude – 8,297 feet.  Once I donned my 30-pound pack, I really felt the altitude.  Carrying a pack uses all kinds of muscles that, at least with my day-to-day activities, don’t get used much.  I was very, very grateful for all those hours and miles of schlepping that increasingly heavy pack all over Seattle and the Cascades.  Our awesome guide, Karla Kennedy had many stories of clients and their mistaken belief that distance running, swimming, Cross Fit, weight training, Zumba, etc. would be enough.  As the early emails from the guiding company had stated, the best training for schlepping a pack is schlepping a pack.  So that was lesson number one.  Train!  Train right!

Karla, a 40 something biologist by training and experienced Grand Canyon guide, had an amazing depth and breadth of knowledge about back country trekking, botany, geology, and history relating not just to our endeavor at hand but life in the outdoors in general.  Her hard skills were surpassed only by her soft skills. Within minutes of our departure from the North Rim, she established a hierarchy within our group. My husband, who is the nicest guy on the planet, likes to be in charge on the trail.  After all, he’s summited Mt. Rainier many times, summited Denali once, has trekked in the Himalayas, has ice climbed in B.C., backcountry skied all over the United States and Europe and lived to write about it. He knows what he’s doing.  But……………..Karla, without Nick even noticing, assumed the alpha role with authority laced with good cheer.  So that was lesson number two.  Someone needs to be in charge and hierarchy, which has gotten a bad rap in the Woke World, serves an important purpose in serious endeavors.

Fortunately for my oxygen needs, but unfortunately for my quads, the first day was a steep downhill 8 miles to a breathable altitude of 4049 feet.  We soon got into a rhythm and I was very grateful for the pacing imposed on our group by our wonderful guide. Normally, when I hike with Nick, it’s a grueling blast to the top of the peak.  Just get there.  That usual M.O. would not have worked on this trip. Just when I was feeling really, really fatigued and cranky, Karla would read my mind (I never once complained, really) and we would take a break.  Off with the packs.  Another sip of water and then a hearty snack.  We had oodles of snacks, Karla’s orders.  My favorites were Cliff Bars with Megan Rapino or Venus Williams, two of my favorite badasses, on the wrappers.  Enjoy the view, enjoy the moment, regroup, eat up, feel that blood glucose level inching up and hey, look at these fossilized lizard foot prints on this rock. They are one bajillion years old.  Then back with the pack and onto the trail.  This was our routine for the 4 days of the trip.  Lesson number three.  It’s okay to rest and snack!

And now that I’m back home and working on my memoir (working title is The Human Condition: Sometimes It Isn’t Pretty), I think about my long career in surgery and how these lessons did or did not apply.  The first one certainly did. There is no way to learn to be a surgeon except to operate. You start slow and small and with a lot of supervision.  You build on your skills and learn new ones.  There is no substitute for putting in the time and getting those case numbers.  Attention medical students looking at surgery residencies:  Go for the programs with high volumes.  All the academic yada, yada, yada in the world will not make up for time not spent in the operating room.

The second lesson of hierarchy has been under attack in medicine for most of my career. (And do not confuse hierarchy with assholery.  There is no place for assholes in medicine.)  While it is important for all members of a surgical team to be heard and respected, the surgeon remains, as he or she must, the captain of the ship.  Any misadventure in the operating room, regardless of the cause of such misadventure, becomes the surgeon’s problem.  The forgotten epinephrine in the liposuction tumescence solution?  Umm.  The nurse forgot but it’s the surgeon who must deal with the bleeding and explain to the patient why the case was not completed as planned.  The pregnant nurse tripping over the IV pole and sending it crashing onto an asleep patient’s face?  Umm.  It’s the surgeon who assures the patient and his family that nothing was broken and those bruises should fade in a couple of weeks.  That piece of belly button fuzz (ewwwww) missed during the surgical prep?  Umm.  That postoperative wound infection will be the surgeon’s problem.  Thus, the person with the responsibility, the surgeon in the OR and Karla on the trail, must be the person with authority.

The third lesson?  Rest and snacks.  Geeze, I wish I had embraced that concept during my career.  It’s not unusual for a surgeon to operate 4, 6, or even 8 hours without taking break.  It’s truly crazy to work that way considering that a quick break to stretch, down a Megan Rapino or Venus Williams Cliff Bar and a glass of water and a quick trip to the ladies (or gentleman’s) room would only take, really, about 6 minutes assuming there are no fossilized lizard tracks to contemplate. Then, back the surgeon could come to the OR, refreshed and strong.  I’m convinced it would actually speed up the completion of a case.  Typically in a long case, the nurses, techs and anesthesiologist get spelled but not the surgeon. So why, why, why?  It’s a culture thing mostly.  And honestly, it took this backpacking adventure to even put the idea of planned breaks in my head.  If you are a surgeon, young or old or in between, consider taking a break during those long cases.  It won’t make you less badassy than you already are.  Just tell the staff that it’s Karla’s orders.

Thanks for reading!  Dr. Lisa Lynn Sowder (blissfully retired)

I’d be honored if you followed me on Instagram @lisalynnsowder, @sowdermd and @breastimplantsanity.

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Meet Dr. Hakim Said!

May 23rd, 2021 — 8:58am

My last day of surgery was last Friday (5/21/21) and my very last day of practice is June 1st.  My 30 years of private practice have been a pleasure and a privilege.  I thank all of my wonderful patients and my wonderful staff for a great run.

I am very pleased that Dr. Hakim Said will be joining the practice on June 2nd.  He is currently offering consultations and I highly recommend you consider him for your plastic surgery.

My web site will be undergoing a radical pruning in the coming weeks.  I plan to trim it down to my blog which I plan on continuing.  Stay tuned for a wide variety of blog posts now that I have time to pursue my many non-medical interests!

I also plan on continuing my Instagram accounts – @lisalynnsowder, @sowdermd and @ breastimplantsanity.

Onward.  Dr. Lisa Lynn Sowder

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To everything there is a season………………………

December 1st, 2020 — 10:46am

It is with mixed feelings I am announcing my retirement this June, after 30 years of practice.  I know it’s cliche to say that time as flown but it really, really has.  Plastic surgery has offered me everything in a career that I could have asked for.  It allowed a biology geek like me to embrace the science of medicine and surgery and also kept my very restless physical self moving and allowed me the ultimate joy of working with my hands, all while serving a wonderful group of patients and working with incredibly talented staff and colleagues.

Sooo……..if you are a current or past patient, I will be doing my last case in the OR sometime in mid-May.  The office I share with Dr. Shahram Salemy, Madison Tower Plastic Surgery, will be welcoming another plastic surgeon.  This individual will be well trained and experienced and likely taller and much younger and maybe even nicer than me.  Madison Tower Plastic Surgery will maintain all patient records should past patients need access to them.

What about this glorious web site? I know my website is short on style and bells and whistles but have been told many times how helpful the content is.  I have been nurturing my web site for 20 years and it is almost like a child to me. Yeah, I know that’s weird.   I am making the tough decision to whittle my web site down to include only my blog – Notes of a Plastic Surgeon.  I will continue to post on this blog from time to time about all kinds of topics. I suspect my range of topics will expand mightily once I have the time to pursue many interests that have been sidelined during my medical training and career.  I am also planning on keeping my Instagram accounts – @sowdermd, @breastimplantsanity and @lisalynnsowder.

So what’s next for me?  Hmmmmm. I’ll keep you up to date on my blog!

I thank each and every one of you who have supported me in this glorious career!

Dr. Lisa Lynn Sowder

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From the Wall Street Journal, June 10, 2020

June 11th, 2020 — 10:10am

Thank you for reading.  Be kind.  Stay strong. Dr. Lisa Lynn Sowder

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Returning to Elective Surgery in the New World Order of COVID-19.

May 11th, 2020 — 12:41pm

 Washington State is starting to open up following our stay-at-home order.  I am really looking forward to getting back to what I love – taking care of patients.  We have worked very hard along with our national societies and governmental agencies to put in place procedures to keep ourpatients and ourselves as safe as possible.  I am over 60 as are three of our four anesthesiologist and our nurse manager and you will find us here, doing our jobs.  We would be foolish to pretend that there is no increased risk during these times. 

SMALL BUT NASTY

We have put together the following informed consent form for patients during this time.  Like all informed consent forms, it is meant not to frighten but to rather inform patients and remind them that surgery, even elective plastic surgery, is never risk free.  All patients undergoing surgery during this pandemic will be given this form and be required to sign off on it.  And remember, me and my staff are signing off on this increased risk every day we show up for work.  Should you have questions about our protocols, don’t be afraid to ask!  

 

 COVID-19 RISK INFORMED CONSENT

 I                                               (patient name) understand that I am opting for an elective treatment/procedure/surgery that is not urgent and may not be medically necessary.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing.  I recognize that Dr. Shahram Salemy and Dr. Lisa Sowder and all the staff at Madison Tower Plastic Surgery and Madison Tower Surgery Center are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for Dr. Shahram Salemy and Dr. Lisa Sowder and all the staff at Madison Tower Plastic Surgery  and Madison Tower Surgery Center to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure/surgery itself.

I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure/surgery.

 

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

 

 

 

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A must read article about COVID-19

March 19th, 2020 — 1:52pm

Please read this article for some excellent information of COVID-19.  

My office and ambulatory surgery center is shutting down for at least a month.  We will have a skeleton staff answering the phone and I will be available in person for only those who really need a face to face with me.  I am 63 and thus at high risk despite enjoying excellent health and feeling and sometimes acting like I’m 14.  I thank all my patients who have had to reschedule their surgery and I thank everyone who takes this seriously.  And for those who don’t, get a clue already.

Stay safe, stay strong, stay sane, and stay in touch.

Dr. Lisa Lynn Sowder.   Follow me on Instagram @sowdermd and @breastimplantsanity.

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Can Surgery Be A Placebo?????

February 21st, 2020 — 11:45am

A few weeks ago I listened to an excellent Hidden Brain Podcast about placebos and not just the sugar pill kind of placebo.  This podcast recounted an amazing clinical trial done way back in 2002 which put the very common procedure of arthroscopic knee surgery for osteoarthritis to the test.  I will summarize that study here but I really encourage everyone to listen to the podcast.  There are also some links to the original paper published in the New England Journal of Medicine.

In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.

So here we go with my summary:  180 patients with osteoarthritis of the knee were randomly assigned to one of three groups.  The assignments were controlled for severity of disease.

Group 1 : Routine arthroscopic surgery to wash out and clean up any irregularities in the knee joints

Group 2:  The incision was made, the arthroscope was inserted and the knee joint washed out (lavaged) but nothing else was done.

Group 3:  An incision was made but the arthroscope was never inserted.

The patients did not know which group they were in nor did their families or the nurses who cared for them after surgery.   The surgeon and the operating team did not know which procedure the patient would have until the patient was on the OR table and anesthetized and the randomization envelope was opened.  For groups 2 and 3, a video of standard knee surgery was played and the OR team sort of faked the movements of the surgery and the time in the OR was the same for all groups.  One surgeon did all of the cases.  Group 1 is the real operation, Group 2 is the lavage group and Group 3 is the sham procedure.     Now some commentary on this study.  These patients had honest to goodness osteoarthritis of the knee confirmed by history, exam and X-Rays.  This was not a group of patients with ill defined and subjective complaints.  These were patients with objective disease. .

Follow up at two years showed no statistically significant difference in relief of symptoms as reported by the patients or function as measured by walking and climbing stairs between Group 1 (real surgery), Group 2 (lavage only) and Group 3 (sham surgery).   Think about this for a moment……….An arthroscopic clean out of the knee joint had no more effect than a superficial skin incision.  

I remember the reaction to this study when it was published.  At that time I did a lot of my surgery at Seattle Surgery Center and I had the opportunity to hob nob with a lot of orthopedic surgeons.  The ortho bros often teased me for all the unnecessary surgery I do.  Yeah, it’s true.  The vast majority of cases I do are unnecessary.  This study allowed me to tease them about their “scoping for dollars” practices.  I think a lot of scoping for dollars still goes on (mostly because patients request it) but maybe a little less since this paper smacked everyone upside the head.

Isn’t it just amazing what the human mind can do?  It can convince the body that the sugar pill was the real thing or even that the sham surgery was the real thing!

Thanks for reading and really you should listen to this podcast!   And as usual, I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

 

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Some suggestions for New Year’s Resolutions

December 31st, 2019 — 12:30pm

 

I cannot improve on this list of Woody Guthrie’s.

blog new yearsThanks for reading and Happy New Year!

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

Dr. Lisa Lynn Sowder

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Opioid Free Surgery

May 20th, 2019 — 9:08am

I am very pleased to introduce our new opioid free surgery protocol.  This has been in the works for several months and we launched it 3 weeks ago with very good feedback from our patients.  Here’s just about everything you need to know.

Why?    The use and abuse of opioids cause a lot of problems not just for patient but society at large.  On the patient level, opioids often cause side effects such as itching, nausea, constipation, fuzzy head, bad dreams and the list goes on.  Having been on opioids myself for various surgical procedures, I personally think they don’t do a very good job at controlling pain but just get you so fuzzy in the head that you just don’t care.   On a societal level, have you heard of the opioid crisis?  The fewer pills out there in people’s medicine cabinet will mean less abuse.

How?   By approaching anesthesia and post operative pain in a different way, pain control can actually be better than what we have achieved in the past with opioids.  The non-opioid medications are started pre-operatively to provide a preemptive strike against the pain cycle.

What?  Here are the medications we use.  Acetaminophen a.k.a. Tylenol:  It’s good for head aches and post op pain.  Celecoxib a.k.a. Celebrex:  this is a non-steroid anti-inflammatory but does not have the blood thinning effects of other NSAIDs such as ibuprofen.  Inflammation is a major factor in pain.  Gabapentin a.k.a. Neurotin:  This is a medication used commonly for nerve pain.  It has a mild sedating effect in some individuals but does not fuzz your head nearly as much as an opioid.  Marcaine and/or Exparel:  These are long acting local anesthetics that are injected into the operative sites that can render the injected area numb for hours or days.  Ice: Oh, yeah, ice packs can help a lot.  My husband got through a gnarly knee operation with virtually nothing more than Tylenol and a gizmo that surrounded his knee with ice slush, provided by his awesome caregiver (that would be me).

When?  We have out patients take a dose of Tylenol, Celebrex and Gabapentin a couple of hours before surgery with a sip of water.  During surgery, the surgeon injects the operative area with local anesthetic.  After surgery, the patient continues with the medication combination.  Ice packs can be added for most types of surgery but check with us first.

Who?  All of us – surgeons, anesthesiologist, nurses, patients and their caregivers.  This protocol requires that we all work together.  The patients must make sure to take their medication before surgery, anesthesia must minimize or eliminate the use of opioids during surgery, the surgeon must be thorough with injection of the local anesthetics, the nurses must be sure the patients and their caregivers understand the pre and post-operative instructions.

So, how’s it working?  So far I have had a dozen patients on this protocol including a tummy tuck patient with very, very favorable results. I am very excited about this plan.  I’m sure we will tweak it here and there a bit but thus far I’m a total fan.

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

Dr. Lisa Lynn Sowder

 

 

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Capsular Contracture 102: Treatment

April 19th, 2018 — 3:59pm

My last blog discussed the difficult and frustrating problem of capsular contracture of breast implants.  As with just about every problem known to mankind, prevention is the best approach. But despite doing everything correctly pre-operatively, intra-operatively and post-operatively, a small number of patients will experience capsular contracture.

First a little history:  Way back when the Earth was cooling and breast implants were the newest and coolest thing, surgeons would treat capsular contracture by “popping” the breast, the so-called manual or closed capsulotomy.  Here is how it worked.  The surgeon would take his great big strong paws and basically mash the poor breast until there was a pop and the breast went soft as the scar capsule ruptured and released its pressure on the implant.   As you can imagine, there was a lot of moaning and screaming in the exam room during this process.  It wasn’t long before surgeons realized that: 1. the capsular contracture always came back, 2. this can rupture a breast implant, 3. this can cause acute bleeding and 4. women don’t like being manhandled this way.  I was just starting my training in plastic surgery just as manual capsulotomy was falling out of favor.  I’m happy to say that I have never done this crude procedure and it is likely that I would not have succeeded had I tried.  I have teeny tiny and not-so-strong hands.  I would have likely ruptured one of my tendons before rupturing a capsule or implant.

Okay, that was then and this is now.  For early capsular contracture, it’s worth trying medication.  A dozen or so years ago it was observed that implant patients on a certain kind of asthma medication has a very low rate of capsular contracture.  These medications are leukotriene receptor antagonists and they work for asthma by reducing inflammation.  And inflammation is thought to be the final common pathway to capsular contracture.  The two medications used are zafirlukast and mohnelukast.   Accolate and Singular are the brand names respectively.  I have had several patients resolve an early capsular contracture with these medications. I have also had a few patients who did not respond to these medications

These implants were 41 years old and had a grade 4 capsular contracture. I removed them and the capsule and inserted new implants. She is shown 18 months after surgery.

Once a capsule is well established, surgical intervention is the only way to resolve it.  Complete capsulectomy removes the scar tissue and then the question  is how to prevent a recurrent capsule.  And does it make sense to just pop in another implant right away?  This is just such a difficult question because none of us has a crystal ball to tell the future.  Sometimes capsulectomy and a new implant works great but sometimes another capsular contracture starts forming despite doing everything right.  Sometimes we create a new pocket and make a pocket under the muscle if the over the muscle implant had a capsular contracture and vice versa.  Adding Accolate or Singular makes some sense.  Sometimes adding a piece of acellular dermal matrix like Strattice (which should be spelled  $$$$trattice) will decrease the chance of another capsule.  And whenever there are several different approaches to a difficult problem, you can be sure that none of them works every time.

The only surgery I know of that will for sure prevent another capsular contracture is implant removal and total capsulectomy without implant replacement.  This definitive treatment is readily accepted by many of my older patients who are sick and tired of their nasty, rock hard and uncomfortable implants.  They look forward to being implant free.  For younger patients, however, this can be a very, very difficult thing to accept, especially if they were really, really flat to begin with.  I have at least one patient that comes to mind who had several capsular contracture related surgeries by me and finally we just threw in the towel and removed her implants along with her capsules.  Her breasts returned pretty much to their preoperative size and shape but let me tell you, her wallet was never the same.  A problem with capsular contracture can be very, very expensive and result in a lot of down time – off work, off exercise, off fun.  This particular patient went on to have some fat transfer several years later and did well.  She and I are both glad to have her implant saga behind us.

Just writing this post makes me feel like I never want to do another breast augmentation!  And then I think of the patient I saw in clinic this morning.  She was very, very flat chested and was too lean to consider fat transfer.  I inserted 250 cc low profile cohesive gel implants last week and this morning I could not wipe the smile off her face.  I think as long as there is Victoria’s Secret, there will be a demand for breast augmentation.  I am just grateful that implant technology keeps improving as does our surgical technique.  Hopefully sometime in the near future capsular contracture will be of historical interest only.

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

Breast Contouring, Breast Implant Removal, Breast Implants, Plastic Surgery, Uncategorized

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