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: Uncategorized

How to lose weight in 4 easy steps by

February 14th, 2018 — 7:39am

I thought I would post this essay for Valentine’s Day.  It’s really not about losing weight.

This is cut and pasted from  All I added was the cartoon.


I’ve spent the past year losing 80 lbs and getting in shape. A lot of people have been asking me how I did it; specifics like what diet I was on, how many times a week I worked out, etc etc. So I thought I’d just answer everyone’s questions by giving you guys step by step instructions on how you can achieve everything I have… IN JUST 4 EASY STEPS! Ready? Here we go!!!

This is a big one, and one that you’ve probably heard before. Every time you drink a beer, it’s like eating seven slices of bread. That’s a lot of bread!


Portion control according to B. Kliban

Portion control according to B. Kliban

This is especially true when you go out to eat at restaurants. A good trick to do is when your meal comes, cut it in half and right away ask for a takeout container, so that you can save the rest for later – and even better, if you start your meal out right by ordering lean meats and veggies, you’ll slim down in no time!

And not just broken; shattered. Into itsy bitsy tiny little pieces, by a girl who never loved you and never will. Join the gym at your work. Start going to the gym regularly, and even though you don’t know that much about exercise and you’re way too weak to do pretty much anything but lift 5 lb weights and use the elliptical machines with the old people, do it until your sweat makes a puddle on the floor. Then go home and go to bed early and the next day do it again. And then again. And then again.

Listen to stories of your ex-girlfriend fucking around with gross and terrible people, stories from your friends who think they are doing you a favor. Go to the gym and make more puddles of sweat. Buy books. Learn about different muscle groups and how they work together. Start eating healthy. Learn about nutrition. Plan out your week of meals. Try to forget her.

After work one night, go up up up all the way to the top floor of the parking garage and walk all the way to the back. Look out at the twinkling lights of the skyscrapers of downtown Los Angeles and think about how every single one of those office lights represents a person. Try to imagine how they feel. What they’re doing right then; if they miss someone special, if they wonder if someone special misses them. Then realize that most of those lights are probably shining into offices with no one in them except for a custodian or two. Realize you are alone, that you are staring at no one. Turn your collar up against the cold and drive home to a meal of a single chicken breast and steamed vegetables. Go to sleep. Go back to work. Go to the gym. Sweat.

Buy a scale. Pick a goal weight. Imagine the goal weight as a shining beacon on a hill. You are at the bottom, in the dark. Talk to her at work. Notice the awkward way she walks in high heels and her goofy smile when she looks over at you. Feel something clench inside your chest. Think about the gym and what muscle groups you are going to work that night.

Get on the treadmill. Push yourself to level 3, then level 4. Then 6. Run so fast you feel like you are going to die. Hit level 10. Pray for death. Think of how bad she makes you feel. Find the strength to keep going.

Late one night, make the mistake of looking at her Facebook and Instagram posts. Feel lower than you ever thought possible. Unfriend her and try to forget what you’ve seen. She is doing things with other people that you asked her to do with you. She is having a great time without you, and you are wasting your life listening to Taylor Swift on repeat and making sweat puddles on a gym floor.

Watch as your life shrinks down to four things: 1.) work, 2.) the gym, 3.) the food you eat, 4.) sleep. She wears the necklace you bought her and tells you that she got it “from someone who’s really special”. That night you discover that Slayer’s “Angel of Death” might be the perfect song to do squats to.

Start to make friends at the gym. Vince and you spot each other on Wednesdays; Chase and you spot each other on Fridays. You used to look down on bro nods and fist bumps – but since that’s how gym rats communicate, that’s become the language you speak most often. Work, Gym, Food, Sleep. Over and over. More sweat puddles. More fist bumps. You run hundreds of miles and lift thousands of pounds.

You start to see new people working out here and there and you realize you have done something you once thought impossible: You have become one of the regulars. Once in a while, you are the last one leaving the gym. You make a point to get to the gym earlier, but your workouts start to stretch from one hour to ninety minutes to two hours. You are now routinely the last person at the gym. You run. You lift. You make more puddles.

Your body changes slowly, then all at once – you are suddenly thin and muscular. You hit your goal weight, pick a new one, then hit it again. You go out and buy new clothes. You receive wave after wave of compliments. Your ex tells you that she’s seeing someone else. Your chest clenches. You feel exhausted.

That night you go to the gym. You listen to all her favorite songs. You run farther and lift more than you thought your body was capable of. It is a good workout. It leaves you numb. You go home and eat a single chicken breast and steamed vegetables. You go to sleep. You dream of a bottomless black puddle.

You’ve stopped drinking alcohol months ago, so now when you hang out at bars or parties you don’t talk to anyone new. But with your new body and new clothes, gorgeous women hit on you constantly. One time, a woman literally comes up to you and says she thinks you’d be good in bed and hands you a napkin with her number on it. As she is talking to you, her hand resting on your chest inside your shirt, all you can think of is how badly you need to beat your best time sprinting across the park across from your house the next day. That night when you get home you research the best shoes for trail running and click “buy”. The shoes are a hundred dollars. The phone number goes in the trash.

There is a girl you see a lot at the gym, who always does these weird leg exercises you’ve never seen before. She’s beautiful. You make it a point to not look at her – because you are overly worried about looking creepy like that guy in the blue shirt who never wears underwear and always hangs around the lat pulldown machine – but you notice this girl is always at the gym when you are, and seems to always choose the bench next to you. You turn up the Slayer and concentrate on making your puddles bigger.

Your ex parades her new boyfriend around, flatly ignoring you the entire time. He is taller than you, more ripped than you, better looking than you, and – according to the Greek chorus of your mutual friends – he comes from money. As you watch her introduce him to everyone but you, you remember how her blue eyes lit up underneath the ferris wheel on her birthday when you gave her those bracelets she’s wearing. In your pocket, your hand makes itself into a fist.

That night, you deadlift your body weight. You sneak a photo of yourself in the mirror and email it to yourself with the subject heading “You Are A Warrior”. The next day you are disgusted with yourself and delete it.

You make puddle after puddle after puddle and eat single chicken breasts and work and sleep and the weather gets warm and then gets cold and you know all of Taylor Swift’s songs by heart and the only things that exist in the entire universe are you and The Gym and then something different happens: a night comes where you are not the last person in the gym.

It is you and the girl who does the weird leg exercises. You end up walking out at the same time.

Her name is Melissa and she works in the building next to you. She’s worked there for two years. She asks you out to dinner on Friday, promising it’ll be healthy. The leg exercises are Pivoting Curtsy Lunges.

You start seeing Melissa a lot, both inside the gym and out. You tell no one. You add a couple cheat days to your week – for when you two get dinner and share dessert – and you start getting a lot less sleep. You phase out Slayer in favor of Springsteen. Vince and Chase note that you’ve stopped looking like you’re praying for death when you run. Your ex texts you late at night to ask you out to coffee, but you don’t write her back. You can’t remember the last time you fantasized about puddles.

One night you’re walking Melissa to her car in the parking garage and she is parked up up up all the way on the top floor. She says she wants to show you something and she takes your hand and leads you all the way to the back. You both stand there in the dark looking out over the twinkling lights of the skyscrapers of downtown Los Angeles.

“Isn’t it beautiful?” She says. “All those lights.”

You tell her that yes, it’s beautiful, but it makes you sad. All those pretty lights mean nothing; they’re just shining into cold lonely offices with nobody in them. Melissa squeezes your hand and says yes, each light is an empty office – but they’re only empty because the people have all gone home for the day. All those twinkling lights aren’t sad; each one is a person who’s at home, happy with the one they love. And how romantic is that?

You look at her in the lights and she smiles. Something in your chest expands.

Late one Sunday afternoon you are writing out your rent check and realize it’s been exactly a year since you started working out. You think of all those miles you’ve run and those pounds you’ve lifted and chicken you’ve eaten and puddles you’ve made. It doesn’t seem that bad. You realize that it’s not about hitting a goal weight, or lifting a weight. It’s about being able to wait. Waiting, being patient, and trusting that life will slowly inch along and things will eventually get better. After all, change takes time.

But time is all it takes.

Too much sugar!!!




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Thanks for reading and I bet Aaron thanks you too.  I’d be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder




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What might the Cuban Sonic Attacks have in common with Breast Implant Illness?

February 1st, 2018 — 8:49am

You gotta read this from today’s  This will involve some heavy mental lifting so put on your thinking cap and take the time to read the entire article.

Cuba’s Sonic Attacks Show Us Just How Susceptible Our Brains Are to Mass Hysteria
The symptoms so many Americans experienced were probably not caused by a secret weapon. That doesn’t mean they’re not real.

FEB 01, 20185:43 AM

A few weeks after the 2016 presidential election of Donald Trump, several people working for the U.S. Embassy in Cuba fell mysteriously ill. Some lost their hearing. Some had headaches and a pain in one ear. Others reported feeling dizzy or nauseous, having trouble focusing, or feeling fatigued. Later, some would have a hard time concentrating, remembering things, sleeping, and even walking.

These symptoms were “medically confirmed,” as the State Department’s medical director Charles Rosenfarb put it, and brain scans were said to show abnormalities in the victims’ white matter, which transfers information between brain regions. The illnesses were believed by the government to be “health attacks,” carried out by a foreign power, though as Todd Brown, assistant director at the Bureau of Diplomatic Security, told the Senate Foreign Relations Committee, “investigative attempts and expert analysis failed to identify the cause or perpetrator.”

Nonetheless, investigators concluded the illnesses, which ultimately affected 24 people, were likely the result of a “sonic device.” This conclusion seems to be primarily due to the fact that some diplomats reported hearing a high-pitched noise in their homes and hotel rooms.

Despite a lack evidence for such a weapon, or any known way it could affect white matter, the sonic weapon theory proved irresistible for both media outlets and for Cuba hawks like Sens. Marco Rubio and Bob Menendez, both of whom immediately transformed the sonic weapon into a handy political weapon.

In the months following the “attacks,” new diplomats arriving in the country were warned of this sonic danger. Embassy employees were played a recording of what was thought to be the sound so they knew what to listen for. Soon, people at the Canadian Embassy in Cuba began reporting symptoms similar to what the Americans had experienced, as did a few tourists there. A husband and wife at the U.S. Embassy in Uzbekistan became ill as well. Whatever it was, it seemed to be spreading.

There is increasing recognition that these epidemics of hysteria, which usually mirror prominent social concerns, present real individual and public health problems.
With no details, no motive, and no plausible explanation for what kind of weapon this might be, doubts began to surface. The FBI investigated and reportedly found there had been no such attack (though it suggested maybe it was a “viral” weapon). Sen. Jeff Flake also cast doubts on the sonic version of events. A handful of skeptical stories began to appear amid the more alarming ones, suggesting this might be what in the past was known as, “mass hysteria,” but which is now referred to as “mass psychogenic illness,” or a “collective stress response.” (These include things like the twitching girls in Le Roy, New York, in 2011; the 600 paralyzed girls in Mexico in 2007; and the Belgian Coca-Cola scare of 1999, which affected 100 students with more than 900 others reporting a related symptom, and costing the company somewhere between $103 million and $250 million.)

Epidemics of this sort are well-known in the scientific literature. Robert Bartholomew, a New Zealand–based medical sociologist and the co-author of Outbreak! The Encyclopedia of Extraordinary Social Behavior, Mass Hysteria in Schools: A Worldwide History Since 1566, and other books on the subject, has collected a database of some 3,500 cases. While the precise mechanisms are difficult to pinpoint, and the diagnosis is always controversial, there is increasing recognition that these epidemics of hysteria, which usually mirror prominent social concerns, present real individual and public health problems.

Yet many people still assume victims of such phenomena are simply faking or imagining their symptoms. In the Senate hearings on the attacks, Sen. Rubio asked Rosenfarb whether he thought this was, “a case of mass hysteria, that a bunch of people are just being hypochondriacs and making it up?”

This was a loaded question, with Rubio deploying the term mass hysteria as a means of dismissing this possibility altogether. But Rubio’s assumption—that a mass psychogenic illness is the same as faking or hypochondria—is wrong, as was his dismissal of the idea that this might explain the illnesses in Cuba. Indeed, mass psychogenic illness is likely the best explanation for these illnesses. According to Bartholomew, if you removed the word concussion from discussion of what happened there (but left the “white matter tract” changes in its place), you’d have a “textbook case” of mass psychogenic illness, in everything from its symptoms to its spread.

“There’s no evidence whatsoever that this was caused by a sonic device,” Bartholomew says. “It is physically impossible to have brain damage caused by an acoustical device. And most of those symptoms are not symptoms of sonic weaponry.” Anxiety and nausea, he notes, can be caused by both mass psychogenic illness and acoustic weapons, but the noise would have to be incapacitating and high volume. None of the other symptoms reported in Cuba are associated with an acoustic assault.

And what’s more: “This is a small, close-knit community in a foreign country that has a history of being hostile to the United States,” he says. “That is a classic setup for an outbreak of mass psychogenic illness.”

History is filled with cases of “sounds” making people ill. In Kokomo, Indiana, locals have been plagued since 1999 by a low frequency hum, which one resident said caused, “short-term memory loss, nausea, and hand tremors.” In Taos, New Mexico, a similar sound causes resident “sleep problems, earaches, irritability, and general discomfort,” by one account. Similar hums are reported in Bristol, England, and Windsor, Ontario. In 1989, a “Low Frequency Noise Sufferers Association” was formed in London. The people reporting illness from the noise produced by wind turbines have given the phenomenon its own name: wind turbine syndrome.

Unfortunately, it is also possible to lose your hearing without being attacked by a secret weapon. The Handbook of Clinical Neurology volume on Functional Neurological Disorders lists “nonorganic hearing loss” in its chapter on “Functional Auditory Disorders,” alongside conditions like musical hallucinations, misophonia (“hatred of sound”), “acoustic shock” from a sudden noise (symptoms include “pain in or close to the ear,” tinnitus, balance problems, hypervigilance, and sleep disturbance), and others. In Germany, there is a common condition called Hörsturz, which is a sudden loss of hearing related to stress. In 1973, at a nursing school in Papua New Guinea, there was an epidemic in which students were struck deaf, among other symptoms, with no apparent external cause.

“It’s very easy to manipulate people’s physical well-being through giving them expectations about sound,” says Keith Petrie, who researched the power of the mind in relation to wind turbine syndrome. When Petrie and colleagues exposed people to both infrasound and sham infrasound (silence), they found it wasn’t the sound itself, but their expectations—or what’s known as the nocebo effect—that produced adverse physiological reactions. Witnessing another person with symptoms can create an even stronger response, as can the perceived cause.

“When we gave them a plausible, biological explanation,” says Petrie, “it increased their symptoms the next time they were exposed to sound. When we gave them a nocebo explanation—and both explanations were equally credible—their symptoms decreased.”

On the surface, studies like this make it easy to agree with the Marco Rubio line of thinking that sufferers are just faking it. But the people who were told there was a medical reason for the hearing loss are not just imagining the resulting symptoms—they are physiologically real, “medically verifiable,” and cause deep distress, even if they resolve quickly, as most do.
“People suffering from mass psychogenic illness are not hypochondriacs and they’re not all making it up,” says Bartholomew. “It is a real condition with real symptoms. It could happen to anybody.”

There is real crossover between the condition’s mental origin and physical manifestation.
Research into the nocebo effect has been hampered by the ethics of subjecting people to it, but a picture of the mechanisms is emerging. And one important factor is “abnormally focused attention,” as neurologist Jon Stone puts it.

“As human beings, we’re more prone to these phenomena than we like to think,” says Stone, co-editor of Functional Neurological Disorders. “The rate of functional symptom experiences in the general population is very high. People have these symptoms a lot and just normalize them. We’re never very far from a functional disorder.”

What were once known as conversion disorders (meaning the conversion of a mental problem into a physical one) are now referred to as functional disorders. The old terms like psychosomatic or even psychogenic imply a purely mental origin, but the current parlance reflects the more complicated picture, that there is real crossover between the condition’s mental roots and physical manifestation. A “functional disorder means something has gone wrong with the network, the connections, the pathways, as opposed to the physical structure of the brain. And when these functions go wrong, normal sensations like tiredness, dizziness, or pain can grow much worse and become persistent.

One of the findings in Cuba that reporters seized on was the assertion that victims had suffered some kind of head trauma. As Rosenfarb put it, there were “clinical findings of some combination similar to what might be seen in patients following mild traumatic brain injury or concussion.” Here, he appears to be talking about abnormalities in the patients’ white matter, but a concussion isn’t the only thing that can have that effect. White matter changes with experience and learning, and becomes more robust in response to using a given pathway repeatedly. If those pathways are related to a disorder, it may appear in “diffusion tensor imaging” scans as anomalies.

“Diffusion tensor imaging,” says Stone, “is a technique that shows abnormalities in patients not only with minor brain injuries, but also with chronic pain, anxiety, depression, you name it. This is not a mark of brain injury. It’s a mark of brain dysfunction. It’s evidence that they’re ill.”

One problem in understanding the reality of a functional disorder is that most of us, when we are ill, look for a single cause, a simple chain of events that starts with an event, or a germ, and ends with our own misery. But functional disorders don’t work in this linear fashion. They are recursive and multifactorial, a feedback loop between our expectations, emotions, and physiology. According to Mark Hallett, a senior investigator at the National Institute of Neurological Disorders and Stroke, a picture of how they work is beginning to emerge, in a sense that, “when the so-called limbic system of the brain [the part of the brain that drives instinct, mood, and emotion] is overactive, it might induce the different symptoms that arise.”

Which is to say that if we fixate on our naturally occurring experiences and feelings, they can become amplified, particularly if the limbic system is overactivated by fear and anxiety. This creates a kind of loop between mind and body that it can be difficult to get out of, and which can make these conditions difficult to treat.

“It’s very powerful,” says Petrie. And often underestimated. “From the comments I read by the physician associated with the [embassy attacks], it was interesting how he dismissed this explanation” Petrie says. “He didn’t seem to understand how easily this can happen.”

Most people don’t. That includes just about everyone involved in the Cuban attacks. Mass psychogenic illnesses are not as intuitive to grasp as cold or a flu, but they are just as serious, and should be treated as such. In Cuba, they have not been. Instead, a fixation on secret weapons has obscured a real illness with real consequences, one which can not only be “medically verified,” but which regularly afflicts people across the world, and to which anyone with a functioning brain is vulnerable.

Thank you for reading!  Dr. Lisa Lynn Sowder

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

Breast Implant Illness, General Health, Uncategorized

Brazilian Butt Lift a.k.a. Fat Grafting to the Buttocks: Let’s make this safer.

January 31st, 2018 — 12:18pm

Brazilian Butt Lift a.k.a. fat grafting to the buttocks is getting a lot of needed attention considering the comparatively high mortality rate of this procedure.   Several surgical societies have come together to study these deaths and have come up with these following guidelines.  Hopefully this procedure will become safer.  I applaud those who did the heavy lifting and came up with these recommendations.  If you or someone you love (or even don’t love) is thinking about this procedure, make sure their surgeon is aware of and compliant with these guidelines.  A big booty isn’t worth dying for.

Multi-Society Gluteal Fat Grafting Task Force issues safety advisory urging practitioners to reevaluate technique

Dear Colleagues,

An Inter-Society Gluteal Fat Grafting Task Force** has analyzed deaths from gluteal fat injection (“Brazilian Butt Lift” or “BBL”) and offers the following advisory statement:

Not worth dying for.

The death rate of approximately 1/3000 is the highest for any aesthetic procedure. In 2017, there were three deaths in the state of Florida alone. Every surgeon performing BBLs should immediately reevaluate his or her technique.

Some patients have died when their surgeon said they had injected into the subcutaneous fat layer, but all autopsies of deceased BBL patients have had these findings in common: 1) fat in the gluteal muscles; 2) fat beneath the muscles; 3) damage to the superior or inferior gluteal vein; 4) massive fat emboli in the heart and/or lungs. No post mortem has yet shown a case of death with fat only in the subcutaneous space; this means that surgeons have injected more deeply than they had intended. The mechanism of death is presumed to be high pressure extravascular grafted fat entering the circulation via tears in the large gluteal veins with subsequent embolization to the heart and lungs.

The task force, therefore, offers these suggestions*:

1.Stay as far away from the gluteal veins and sciatic nerve as possible. Fat should only be grafted into the superficial planes, with the subcutaneous space considered safest. If the aesthetic goal requires more fat than can be placed in the subcutaneous layer the surgeon should consider staging the procedure rather than injecting deep.
2.Concentrate on the position of the cannula tip throughout every stroke to assure there is no unintended deeper pass, particularly in the medial half of the buttock overlying the critical structures.
3.Use access incisions that best allow a superficial trajectory for each part of the buttock; avoid deep angulation of the cannula; and palpate externally with the non-dominant hand to assure the cannula tip remains superficial.
4.Use instrumentation that offers control of the cannula; avoid bendable cannulas and mobile luer connections. Vibrating injection cannulas may provide additional tactile feedback.
5.Injection should only be done while the cannula is in motion in order to avoid high pressure bolus injections.
6.The risk of death should be discussed with every prospective BBL patient.
These are links to three helpful articles:

Research projects overseen by the task force and funded by The Plastic Surgery Foundation (PSF), Aesthetic Surgery Education and Research Foundation (ASERF) and International Society of Aesthetic Plastic Surgery (ISAPS) are underway. They will correlate deep and topographical anatomy, define danger zones, and try to understand the mechanism of embolization. The ability to safely perform this procedure in the future is dependent upon this research.

Members of the task force have also assisted coroners during autopsies, and this has provided invaluable safety information. If you become aware of a fatality, immediately contact the task force co-chairs care of Keith Hume, executive director of The PSF, at

Your societies will keep you updated with all developments.


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

Thanks for reading and did you know that skating (roller, ice or skis) can really build up your gluteal muscles?  Just check out the Olympic skaters and skier this winter!  Dr. Lisa Lynn Sowder



BIA-ALCL: What we know so far.

January 8th, 2018 — 3:13pm

I recently took an excellent online tutorial on Breast Implant Associated Anaplastic Large Cell Lymphoma presented by Dr. Mark Clemens of M.D. Anderson Cancer Center.  Here is some information from that tutorial as well as information from the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery.   I have also included information from an article in JAMA (Journal of the American Medical Association) Oncology published last week and some of my own take on this really weird disease.  Warning: this is a long one.

This is a schematic of BIA-ALCL. It is not breast cancer. It is cancer of the breast implant capsule.

Q: What is BIA-ALCL?

A: BIA-ALCL is a rare type of lymphoma that has been found in proximity to breast implants. BIA-ALCL is not a cancer of the breast tissue itself.  It is cancer of the breast implant capsule.  How weird is that???

Q: What are the symptoms of BIA-ALCL?

A: BIA-ALCL usually develops as a swelling of the breast 2 to 28 years after the insertion of breast implants, which may present as fluid collecting around the implant. It can also present as a lump in the breast or armpit.

Q: What is the risk of developing BIA-ALCL?

A: Early in 2016 the FDA issued a report that it had received 258 adverse event reports of breast implants and ALCL. For a frame of reference, both ASPS and ASAPS data report that approximately 300,000 breast augmentations are performed annually.

A: The lifetime risk for BIA-ALCL in previous epidemiological studies ranges from 1:30,000 to 1:50,000.

A: The figure derived and issued by the Australian government was in the range of 1:1,000 to 1:10,000 for Australian/New Zealand patients with textured/polyurethane implants. Polyurethane implants are not available in the United States.

A.  An article published last week (Jan. 4, 2018) in JAMA Oncology and picked up by Newsweek looked at the a large number of women with breast implants in the Netherlands.  Almost one half of the implants used in the Netherlands are textured.  This is in contrast to the implants used in the United States which are mostly smooth.  This study confirmed that this disease occurs with textured breast implant, particularly implants with macrotexturing.  The implant specific risk in macrotextured implants like those made by Allergan and Biocell was 1:3817.  The risk in microtextured implants like those made Silimed was 1:7788 and by Mentor was 1:60,631.  The reasons for that difference is not yet clear but may be related to the increased surface area of the macrotextured implants which could allow for greater bacterial contamination.

A.  Risk may also be somewhat influenced by geography (where you live) and genetics (who your parents are).  There is increasing evidence that certain bacteria and bacterial biofilm may be causative.  Infectious agents are a cause in several other types of tumors such as liver cancer (hepatitis virus) and Burkitt’s Lymphoma (malaria and Epstein Barr Virus).  There are also many cancers that tend to run in families such as breast and ovarian cancer, some colon cancers, leukemia, malignant eye tumors to name a few.  There may be a genetic susceptibility to BIA-ALCL.

Q:  Is there such a thing as ALCL in breasts without implants.

A:  Yes but it is very rare.  According to the recent JAMA report out of the Netherlands, the risk of ALCL in the absence of implants is 1 in 35,000 at 50 years of age and 1 in 7000 at 70 years of age.  The risk in women with implants (all types) is 1 in 7000 at 75 years of age.  By contrast, the lifetime risk of breast cancer for women according to the National Cancer Institue is about 1 in 8.

Q: How is BIA-ALCL treated and what is the prognosis?

A: Current recommendations for the treatment of BIA-ALCL call for bilateral capsulectomy and removal of the breast implants. In all but a few cases, the disease has been fully resolved by this surgery alone. The majority of patients require no additional treatment.

Q: Are some patients at greater risk than others?

A: It is not possible to predict who will develop BIA-ALCL, and while the Australian Government reports a higher risk of BIA-ALCL in those patients with textured/polyurethane implants, the data is not yet well established. This risk remains far less than that other known risks, such as capsular contracture.

A: It has occurred in women who have breast implants for both cosmetic and reconstructive purposes.

A: BIA-ALCL has occurred in women with both saline and silicone implants.

Q: Should patients have their implants removed?

A: Neither the FDA nor the Australian Government’s report suggest additional screening or removal of implants for asymptomatic women.

Q: Should women with breast implants be screened for BIA-ALCL?

A: Expert opinion is that asymptomatic women without breast changes do not require more than routine follow-up. If a patient experiences a change in her breasts – especially if there is swelling or a lump – she should undergo examination and appropriate imaging, including ultrasound and fine needle aspiration of any peri-implant fluid.

Q: What causes BIA-ALCL?

A: ASPS, ASERF, the FDA, and the implant manufacturers are working proactively to study BIA-ALCL. To date, no specific causal factors have been identified. Implant texturing, bacteriologic contamination, and genetic factors have been implicated and are undergoing further study.

A: Bacteria have been identified within the lymphoma and around implants in affected breasts, and there is accumulating evidence that a long-term inflammatory response to the presence of these bacteria is one of the factors that may cause BIA-ALCL. Research is ongoing and cases are being monitored through the PROFILE registry.

A: Genetic factors may play a role. The Australia/New Zealand risk appears higher than other studies have indicated. Some geographic areas have reported very few cases. Ongoing data collection worldwide will help to determine whether or not there are any genetic propensities for this disease.

Q: Do ASAPS and ASPS recommend against the use of textured implants?

A: The available data does not support discontinuance of textured implants. The best practice is always for the physician to discuss with each patient the known risks and potential complications associated with any procedure. It is important for the patient and her doctor to frankly discuss all options available, and the risks involved.

A: Every plastic surgeon offers patients options regarding breast implants in terms of sizing, shape, and surface. Textured implants may offer advantages when placed subglandularly (lower risk of capsular contracture), and when an anatomically shaped implant is utilized (lower risk of malrotation). Depending on a particular patient’s needs, a textured implant may be preferable. The plastic surgeon must provide a frank and transparent discussion regarding the benefits and risks of implants, both smooth and textured. The patient must then make an informed decision, based upon her own assessment of her needs and the risks involved.

A: Every plastic surgeon needs to help each individual patient make her own decision about which implant she prefers in a fully transparent manner. This involves weighing any possible increased risks against the advantages offered by a particular type of implant. It is critical that the patient makes a fully informed decision following a full discussion of the risks and benefits.

Q: What does Dr. Sowder think of textured implants?

A: Geeze, I’m glad you asked.  I have never been a big fan of textured implants and have used them very infrequently over the years.  The main reason for this is that I do not use many anatomic (tear drop shaped) implants which are always textured.  I have found these implants, in my hands, to require more revision that smooth, round implants.  Also, and I have blogged about this many times, I don’t think anatomic implants make a difference in the vast majority of patients so there is not reason to use them.  Anatomic implants are textured so they “stick” and stay put and do not rotate or flip.  If a smooth round implant rotates or flips, it does not change the shape of the breast.  I consider myself lucky not to have many patients with textured implants out there.  I am a worry wart by nature.  If my current practice were heavy into textured anatomics, I would be questioning the wisdom of this at least until we know more about BIA-ALCL.  There are some plastic surgeons out there who are very evangelical about using anatomic implants (and often times paid con$ultant$ to implant manufacturers) and rather than say, “Whoa Bessie, let’s see how this all unfolds”, some of them are digging in and minimizing the risk of BIA-ALCL which seems to go up with every new study.  This sort of stuff makes me cranky.  One very difficult issue is that of textured tissue expanders used to stretch out the skin and muscle for implant based breast reconstruction.  All of the expanders are anatomic and thus need to be textured so they don’t rotate of flip. I no longer do breast reconstruction but if I did, I would still use textured expanders because there is no alternative.

Q: Have there been any deaths due to BIA-ALCL?

A: There have been 12 confirmed deaths, including 6 in the United States, attributed to BIA-ALCL since the disease was first reported nearly 20 years ago.

Q: What is the recommended clinical response to a patient presenting with symptoms that could be attributable to ALCL?

A:  As in all diseases, the first step is to establish a diagnosis.  Depending on the extent of the BIA-ALCL, treatment would always involve implant removal and total capsulectomy and, if indicated, chemotherapy.  The recent JAMA article reported over 90% of women who underwent proper therapy as having complete remission.

A: In July 2016, ASPS and ASAPS issued a joint “Tear Sheet” describing the recommended clinical protocol for patients presenting with symptoms that could be attributable to BI-ALCL. For a copy of the ASPS/ASAPS Tear Sheet please go to: Joint-ASPS-ASAPS Statement On Breast Implant-Associated ALCL

Access on the ASAPS website at:

This protocol formed the framework for the international recommendations by the National Comprehensive Cancer Network (NCCN) for the diagnosis of BIA-ALCL and can be accessed at

Q: How is BIA-ALCL diagnosed?

A: If a woman develops swelling in an augmented breast, she should undergo an ultrasound scan. If fluid is detected, it should be drained and tested with CD30 immunohistochemistry to diagnose BIA-ALCL. Mammograms are not useful in diagnosing BIA-ALCL. In confirmed cases MRI and PET/CT scans may be performed to help stage the disease.

Q: How is organized plastic surgery working with the FDA to study BIA-ALCL?

A: The Plastic Surgery Foundation (PSF) created PROFILE (Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma, Etiology and Epidemiology) in 2012, a collaboration with the FDA. Any suspected or confirmed cases of BIA‐ALCL should be reported for inclusion in the PROFILE registry at

A: PROFILE is collecting data both retrospectively and prospectively on confirmed cases of BIA-ALCL.

A: The primary goal of PROFILE is to better understand the role of the breast implants in the etiology of BIA-ALCL. The research hopes to identify potential risk factors, diagnostic predictors, and the best ways to manage this disease. In addition to providing health care practitioners and patients with information about the diagnosis and treatment of ALCL, the confirmed cases will assist with further analytical epidemiological studies.

Q: Where can I find more information on BIA-ALCL?

A: Additional information and resources on BIA-ALCL are available online at and by searching “ALCL” on RADAR.

Reporters seeking information or plastic surgeons contacted by a member of the media are encouraged to forward inquiries to Adam Ross, ASPS integrated communications manager at or 847-228-3361. ASAPS members are encouraged to contact Leigh Hope Fountain, ASAPS director of Public Relations, at or 561-7917



The Opioid Crisis and the Post Surgical Patient

December 11th, 2017 — 12:42pm

It seems that not a day goes by when we are not hearing more bad news about America’s opioid crisis.  And with good reason.  This crisis is ruining the lives of the abusers and those who love and depend on them.  A recent photo  spread in the New Yorker Magazine laid it all out in clear and agonizing black and white. So what is a surgical practice like mine doing to respond to this crisis?

Just about every operation I do causes a significant amount of postoperative pain for which I usually prescribe an opioid.  In the 26+ years I have been in practice, I have seen only a few patients who I felt were getting habituated to the medication I prescribed.  And in those cases, I take a straight forward:  “I am worried about your narcotic use” approach.  To my knowledge, I have not had a surgical patient become an addict. 

It is a fine line we have to walk between over prescribing and under prescribing.  Most patients are seen maybe 3 – 7 days after surgery for dressing changes, drain removal and general checking in.  We try to prescribe enough medication to last until that first post op appointment.  If a patient runs out of their narcotic pain medication, we cannot phone in a prescription.  The patient or their caregiver must come to the office to obtain a “hard copy”.  This can be a real burden for the patient.  Often we will write an additional prescription for the patient to fill in the event they run out prior to an office visit.  We emphasize that if the prescription is not used, it should be destroyed.  Likewise, all unused medication does not belong in the medicine cabinet “just in case”.  It should be destroyed or returned to the pharmacy for proper disposal.  There is evidence that diversion of narcotics is a driver in addiction.

We also try to help with pain control with non-opioids.  Almost all tummy tucks get an On-Q pain pump that helps with postoperative discomfort for the first three days after surgery.  We use instillation and injection of long acting local anesthetics to take the edge off of surgical pain.  And once a patient is about 5 days out from surgery, we do out best to get them onto an NSAID and off their prescription pain medication.

Research has shown that it is when opioids are used for chronic pain conditions, patients are much more likely to fall into habituation and addiction.  Opioid use for acute pain (like post operative pain) usually is temporary and most often discontinued by the patient with very few problems.  Most of my patients do not like the way they feel on narcotics and are anxious to get off.  An occasional patient really likes that loopy and foggy feeling that narcotics provide and those are the ones that we worry about.  Again, I take a straight forward approach “You like this medication way to much.  Time to get onto an NSAID.”

On thing that has really changed with the new laws regarding phoning in narcotic prescriptions is the steep decline in bogus phone calls to the doctor on call from drug seeking individuals.  When I was in a large call group years ago, it was not unusual to get one or more of these bogus calls on a weekend.  These calls could be very troubling for the doctor on call because it was often difficult to sort out a legitimate patient and a bogus caller.  What is worse:  phoning in a script for Vicodin to be abused or diverted or not providing relief to a postoperative patient?

One thing everyone can do to help fight this crisis is to take a look in your medicine cabinet.  Are there unused prescription pain pills in there?  If so, take them to our nearest pharmacy for disposal.

Thanks for reading.  Dr. Lisa Lynn Sowder


Nipple Piercing Smackdown

December 5th, 2017 — 10:24am

About two weeks ago I got a whole bunch of sort of nasty emails from professional body piercers slamming me for both my technique for piercing inverted nipples and also for my fees.  It seems they were having some sort of body piercing summit and someone stumbled across my webpage on this topic.  I was able to engage a couple of these piercers and it was interesting to compare notes.  It turns out that my technique is pretty similar to theirs.  I use a suture to pull out the nipple and they either pop it out with pressure on the areola or they grab it with some toothed forceps.  The hardware I use is the same as some of the piercers and I was relieved that my supplier, Body Circle, was well thought of.  One big difference is that I use an injection of Lidocaine (the same stuff your dentist uses) to numb the skin and the tissue deep to the skin so that after the initial “ouch” of the Lidocaine injection, the procedure is pain free.  The piercers all thought this Lidocaine injection was totally overkill.  Two issues here.  Piercers don’t have access to injectable Lidocaine and are not licensed to inject it and maybe more important, some in the piercing and body modification culture consider pain and suffering an integral part of the whole experience.  I have discussed this pain and suffering issue with several heavily pierced and modified patients including one with a forked tongue.  I avoid pain and suffering both in myself and my patients and use a nice big dose of local anesthetic.  I also think epidurals for childbirth is the best thing since microwave nachos but that is another can of worms.

John Durante of Evolve Seattle Professional Body Piercing

I was also taken to task (and given a one star review, ouch) on my Facebook page by this fellow, John Durante, who is professional piercer in Seattle.  He apparently does lots of inverted nipples.  He calls my fees extortion.  Double ouch.  My guess is that my overhead is a little higher than his.  I do know that my fee for correcting inverted nipples (as of this post $500 for one side and $600 for both sides) is a fraction of the fees for invasive correction that destroys the ducts and doesn’t work any better than my piercing technique.

When I started doing this procedure about 15 years ago, many of my patients came in after being turned down at a piercing parlor.  Maybe that has changed.  I think it is great that patients have a choice and I would love to hear about any experience anyone reading this post has had with their inverted nipples being pierced by another doctor or a professional piercer.  Shoot me an email.

Thanks for reading and check out my Instagrams @sowermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

And this just in as of 6/21/18.  I have heard from a very nice piercer named Levi that the following piercing establishments in Seattle can pierce inverted nipples:  They are Slave to the Needle, Laughing Buddha and Evolve Body Piercing.  This is second hand information and I cannot vouch for the quality of their work.  There is also a safe piercing website that has information about piercing.



Price Transparency (or lack thereof) in Healthcare

October 16th, 2017 — 10:29am

Recently my head almost exploded over a price quote from the great big gigantic medical center (GBGMC) across the street.  I have surgical  privileges at the GBGMC but do almost all of my surgery cases in my office ambulatory surgery center (ASC).  My ASC is fully certified, much more convenient and private for patients and much more affordable.  But it took a few phone calls yesterday to the GBGMC to realize how much more affordable my ASC was for private pay patients.

I have a prospective tummy tuck patient who is a little borderline for doing in my ASC because of her age and a few medical issues.  I would kind of like to do her in the GBGMC with an overnight stay.

My patient care coordinator spent two days trying to get a tight price estimate for the 4 hour tummy tuck.  So here are the 4 different quotes we got from various employees of the GBGMC for facility fee which means the use of the operating room.  These quotes did not include anesthesia and do not include my surgeons fee.   Are you ready?  $41,650, $53,550, $70,000 and $90,000. I am not making this up.  Anesthesia costs were real steal at about $13,000.  Hmmm – that means the anesthesiologist is charging way, way more for the anesthesia than I am for the surgery. And the anesthesiologist provides zero follow up care.

Now these prices are just mind blowing but the other thing that drives me nuts is that we got 4 different quotes.  How on earth can a patient budget for surgery when the price could vary by over 100%?

So does the GBGMC really rake in $90,000 for a 4 hour surgery.  Well, maybe from a private pay patient who happens to be a member of the Saudi royal family, but never from an insurance company.  You see, the GBGMC charges this but the insurance companies have cut a deal with the GBGMC and they pay a steeply discounted rate.  This, gentle readers, is one of the things that is really, really dysfunctional in our heath care system.  Nobody really knows how much things really cost, unless of course you are paying out of pocket at a clinic like mine where we put everything in writing and I even post price ranges on this website.

As for my sweet patient who, by the way, is not a member of the Saudi royal family.  I think I will do her in my ASC and have her hire a home nurse for a day or two.  Geeze, for the facility fee of the GBGMC, we could hire a home nurse for a year!

Thanks for reading and when you go in for a medical procedure, ask how much it is going to cost.  This will not be a welcome question but I think the more pressure applied to the health care industrial complex for price transparency, the more likely we will see a change in how the big business of health care is done.

Thanks for reading and follow me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder


My Annual Chico Retreat

September 11th, 2017 — 2:59pm

Cowgirls left to right: Ginny, Patty, me, Stacy and Janis. This was just before dinner at the Yellowstone Club in 2016.

Later this month I’m heading to Chico Hot Springs in Montana for my annual Cowgirl Retreat with 4 of my best buddies from – gasp – high school.  We’ve been doing this every September for twenty years or so.  We are all pretty fit so we usually do a couple of hikes, one easy and one badass.  But mostly we stand around in the big, naturally heated hot spring pool and catch up on each other’s lives.  One thing that is a little weird is that we are all in health care.  I’m a physician.  Patty is a veterinarian, Stacy is an OB-gyn nurse, Ginny is a nutritionist, and Janis runs an ultrasound department.  So, yeah, we’ve been know to talk shop a little bit but it’s mostly about husbands, ex-husbands, children, grandchildren (!), the good old days and how lucky we are to be happy and healthy and together again for a few days.

Thanks for reading!  Dr. Lisa Lynn Sowder.


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

Fear and loathing and surgical drains.

July 19th, 2016 — 8:57am

Seattle Plastic Surgeon answers FAQ:  Will I need a drain?  How long will it need to stay in?   Isn’t a drain really gross?  Won’t it really hurt when you take it out? 

faq blake drain

A Blake drain and its bulb reservoir.

Whether or not a patient will need a drain after surgery depends on what procedure is being done and how much postoperative oozing is anticipated.  Beware of the surgeon who says I always use a drain or I never use a drain because every case is unique because every patient is unique.

I almost always drain my tummy tuck patients, but occasionally there is a patient who is very slim, has almost no oozing at the time of surgery and who I just know (call it surgeon’s instinct) will do fine without a drain.  On the other hand, I rarely drain my breast lift patients, but once in a while, I will get a patient who is really, really juicy (sorry, but I can’t think of a better word) and I know that if I put in a drain for a few days, she will have less swelling and bruising after surgery.

The important thing for patients to know about drains is that they are a temporary annoyance but provide a very important function.  Drains help get all the blood and serum that weeps from the surgical site to the outside.  Having blood and/or serum build up in a surgical wound can cause swelling and bruising and discomfort and can even complicate healing.

Taking care of a drain is an easily learned task and is much less gross than changing a diaper or, in the case of my house, mopping the kitchen floor.

The drain stays in until the drainage is minimal, usually less than 25 ml (that’s about 1/2 a shot glass) for 24 hours.  A drain after a lower body lift may stay in a week or more.  A drain after a facelift may be ready to come out the next day.  Again, it depends on the patient.

Another important point is that drain removal is not very painful.  The drain usually slips out quite easily and the sting associated with drain removal is over in a few seconds.   Many of my out-of-town patients have their caretaker remove their drain when the time is right.  I show them the steps, we set up a phone call and I walk them through it.

Bottom line:  Fear not the drain.

Thanks for reading!  Dr. Lisa Lynn Sowder



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