A ^Retired Plastic Surgeon's Notebook

MRI is the best test for detecting implant rupture (other than surgery) with a very high accuracy rate, much higher and mammogram, ultra sound or physical exam.  I think it is prudent for patients with gel implants, say 10 years old or older to get an MRI to make sure there is not a silent rupture.  If a patient has saline implants, there is no possibility of a silent rupture so an MRI would be worthless unless there is another reason for MRI (cancer detection for example).  I often have patients who are coming in to have their old gel implants removed regardless if they are intact or ruptured and in those cases I don’t really think an MRI is absolutely necessary.  Yes, it is nice for the surgeon to know ahead of time if there is a rupture but honestly, I approach every implant removal as if the implant is ruptured.  I try to do an en block resection and have everything ready in the event the implant is ruptured and there is silicone spillage.  We have special suction set up for ruptured implants and also some old fashioned surgical lap pads ready for clean up.  And even with a rupture, it’s usually not as messy and one might think it would be.  Even the messiest cases almost always allow the surgeon to scoop out the gel and then get all of the capsule.

“Just relax. It doesn’t hurt one bit but it is a little noisy.”

In Seattle at Swedish Medical Center, as of 2017, an out-of-pocket MRI to rule out breast implant rupture is about $1300 – $2200.  If you pay up front, you get the lower price.  The actual procedure requires the patient to lie prone (on the stomach) with the breasts hanging though these little openings in the MRI bed.  It’s important to lie really, really still for a good image.  MRI does not involve any irradiation so don’t worry about that but it can be kinda noisy with pings and dings.  When I had my knee scanned, they gave me earplugs. And after an MRI, please make sure you get the radiologist report.  It is more useful than the actual MRI itself.  Plastic surgeons are not experts at reading MRI’s although we can usually see an obvious rupture. More subtle things may not be obvious to us.  

Thanks for reading and if you are concerned about your oldish gel implants and an MRI will either ease your mind or prod you into action, you should get one!  If are ready to bid goodbye to your oldish implants regardless of their status, come on in.  I’m here to help!

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

The Placebo Effect and its evil twin, the Nocebo Effect.

I’ve been doing some interesting reading lately on the mind/body connection in preparation for a presentation I am giving at the annual meeting of the Northwest Society of Plastic Surgeons this month.  I have been reading up on the “Nocebo Effect” which is the evil twin of the much studied and celebrated “Placebo Effect.”  Any one who has kissed a child’s owie is well acquainted with the placebo effect.

The nocebo effect is a more recently studied phenomenon.  One nocebo effect study involved giving a fake lactose solution to a group of participants which included lactose tolerant and lactose intolerant individuals.  44% of the lactose intolerant and 26% of the lactose tolerant reported gastrointestinal distress after ingesting the sham lactose.  The study participants were told that the solution was know to cause gastrointestinal symptoms.   The nocebo effect can be disruptive when it comes to new drug trials.  In some cases almost 10% of the participants in the placebo arms of clinical trials have to drop the study because of adverse effects.  I have come to view the nocebo effect as the Power of Negative Thinking.  We humans are very susceptible to suggestion.

I had a patient recently who came in for removal of her surgical drains after a breast reduction.  She was just a nervous wreck and was clearly bracing herself for the most painful thing ever.  I asked her about her anxiety and she told me she had seen a YouTube video of a young man who had had a gynecomastia procedure getting his drains removed.  He apparently was howling like an injured wolf.  He must have either had a very low pain threshold or maybe he was a drama student?   Anyway, while chatting with my patient, I slipped out her first drain in about 3 seconds.   Then I slipped out the other one.  She was pleasantly surprised at how quick and easy it was.  Yes, it stung a little but no need for howling.  The howling wolf video she saw was the nocebo effect at work.  The nocebo effect is one reason I implore my patient to avoid surgery horror stories before and after their procedures.  For every horror story out there are likely 10,000 undocumented stories of uneventful surgery and recovery.  But uneventful isn’t nearly as interesting as a howling wolf.

Thanks for reading and beware the nocebo effect.   Dr. Lisa Lynn Sowder.

Seattle Plastic Surgeon answers another FAQ.

It is common to combine surgical procedures and often makes a lot of sense to do so.  Combining procedures saves a trip to the operating room, saves some money and consolidates recovery time.  Procedures often done in combination include breast lift with a tummy tuck and face lift with blepharoplasty.

There are some procedures, however, that I will not combine.  Here is an example:  Posterior hip liposuction and facial surgery.  Why?  Liposuction involves some heavy physical labor.  I work up a sweat with most major liposuction cases.  That heavy large muscle effort leaves me with a fine tremor for about an hour or so and I don’t want to do fine facial surgery with a fine tremor.  So can’t I do the facial surgery first?  No that won’t work either.  The posterior hip liposuction requires the patient to be face down on the OR table.  Positioning a patient who has just had facial surgery face down is NOT a good idea.  Another example:  Brachioplasty (upper arm lift) and tummy tuck is not a good combination.  A tummy tuck really leaves the patient without core strength for several weeks so the patient is very reliant on the arms to move around in bed or get up from lying or sitting down.  Arms that are fresh from a brachioplasty are very sore and should not engage in heavy work.

So, when patients are looking at more than one procedure, sometimes it makes sense to combine them but sometimes it doesn’t.  Oh, and one other factor is surgeon fatigue.  Yes, even badass surgeons like me get tired.  More about that in another blog post.

Thanks for reading!  Dr. Lisa Lynn Sowder

Every week I get some questions sent to me by the website RealSelf.  I am always amazed by the many questions submitted by patients sometimes within a day or two of surgery.  I cannot fathom why a patient would turn to an online community of doctors rather than their own surgeon to answer their questions and address their concerns.

OMG. Is that going to happen to me?

And then there are patients who scrub the web for scenarios that are either much better or much worse than their own.  I just don’t get it.

I advise my patients to concentrate on their situation, their surgery, their recovery. Going online and finding someone who is healing quicker than you or slower than you or just differently that you is not helpful and let me tell you, it makes your surgeon a little cranky.

So……………..take your meds as prescribed.  Get some rest.  Drink lots of water.  Go out for a little walk.  Make yourself a sandwich.  Make your caregiver a sandwich.  Clean our your junk drawer.  Questions?  Concerns?  Run them by your surgeon.  Just don’t go online.

Thanks for reading!  Dr. Lisa Lynn Sowder

“And I feel the same way about you.”

Recently I saw a patient who I just did not like.  I did my best to be professional and courteous but there were some very important health issues that he was unwilling to discuss.  It was sort of like he thought I was a technician who could just do what he told me he wanted done.  He had had several body contouring operations by other surgeons over the years to treat his weight problem.  He was unhappy with his surgical result, had had some significant postoperative complications (which he blamed on his surgeons) and he just wanted me to “fix things”.  I wanted to explore his weight issues which included secondary serious medical issues but he would have none of it.  I also wanted to know more about his previous surgery and he wanted none of that either.  He refused to allow me to obtain records of his previous surgery.  I wasn’t being nosy.  I was doing my job.  After about 10 minutes (seemed much longer) of this back and forth, he decided he didn’t like me and left.  I honestly cannot remember the last time this happened and I felt bad that I was unable to establish rapport with a patient.  But I am really, really glad he and I decided to dislike each other before I had a chance to operate on him!  Operating on someone is kind like going steady for several months.  Love my not be necessary but like certainly is!

Thanks for reading!  Dr. Lisa Lynn Sowder

An empty airline is almost as sad and an empty operating room.

Yesterday I had to cancel a case.  This patient was having a tummy tuck and I do not do tummy tucks on smokers.  She showed up for her surgery and confessed that she indeed had not completely quit smoking but was only smoking about 5 cigarettes a day.  Even that relatively small amount of nicotine puts her at significant risk for major healing problems and also puts her at risks for anesthesia problems because of airway irritability and increased secretions.

Soooo……………………we canceled her surgery, much to her disappointment.  This lady had arranged for time off work, child care, a caregiver for herself etc.  I don’t blame her for being disappointed and I have to say that I was a little disappointed too.  I had assembled an anesthesiologist, two registered nurses and a surgical tech not to mention my operating room.   And there we were, ready to go with no patient.  Canceling a case is sort of like flying an empty airliner around.  Lots of overhead but no paying passengers.

I am grateful that this patient was honest with us about her smoking.  I would much rather have an empty airliner on my hands than a surgical complication.  We got her rescheduled for after the first of the year and this time, I think she will take the no smoking instructions more seriously.

Thanks for reading and please don’t smoke.  Sometimes it can just ruin a good case.                                                                                                                                                                                    Dr. Lisa Lynn Sowder

Appeals court affirms previous victory for Utah Society, ASPS, ABPS truth-in-advertising efforts

The 10th District U.S. Court of Appeals in Denver, Colo., on Aug. 31 upheld the September 2013 dismissal of a lawsuit filed by an ENT and oral surgeon against the Utah Plastic Surgery Society (UPSS), ASPS, the American Board of Plastic Surgery – as well as 19 individual plastic surgeons – which had contended that patient-safety education advertisements amounted to monopolistic efforts and messaging that caused direct financial damage to the non-plastic surgeons.

The appellate court decision provides another victory for patient safety and organized plastic surgery, while also serving as implicit validation of the ASPS “Do Your Homework” public-education campaign to improve patient safety.

The plaintiffs claimed in the original complaint that the Utah Society’s advertising – specifically billboards posted along one of Utah’s main interstate highways, as well as media interviews modeled after the “Do Your Homework” campaign – were in violation of the Sherman Antitrust Act and amounted to false advertising claims in violation of the Lanham Act. The plaintiffs asserted that the campaign was deceptive by indicating that cosmetic surgery is safer when performed by plastic surgeons rather than cosmetic surgeons.

The Appeals Court concluded late last month that the plaintiffs failed to show any plausible antitrust or deceptive advertising violation, and it affirmed the previous ruling in favor of UPSS, ASPS, ABPS and the individual plastic surgeons named in the lawsuit.

“This decision further confirms the value and importance of our efforts to instill public awareness on the distinctions between ABPS-certified plastic surgeons and lesser-trained physicians who present themselves as similarly skilled,” says UPSS President Brian Brzowski, MD. “We were helped tremendously by ASPS through its early financial and material support and its guidance in crafting the overall ‘Do Your Homework’ effort.”

“Despite the hurdles we have had to cross in dealing with the lawsuit, I was always supremely confident that we would prevail in promoting safe plastic surgery in Utah and beyond,” adds UPSS immediate-past President Trenton Jones, MD. “This public-safety education campaign was modeled largely after the ASPS campaign, so it’s a victory for organized plastic surgery and a huge win for the Utah Society.”

“We’re pleased that the legitimacy of the public-education efforts of UPSS and ASPS have been recognized yet again by the federal court,” says ASPS President Scot Glasberg, MD. “We applaud the Utah Society for taking a stand for patient safety and our specialty – and we welcome any local, state or regional society to confer with the leaders of the ASPS Public Education Campaign to raise awareness and promote patient safety in their states and localities.”

ASPS acknowledges Dr. Brzowski, Dr. Jones and the Utah Plastic Surgery Society for their efforts to both bring the ASPS “Do Your Homework” campaign to their state, and for defending patient-education efforts.

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon and mother of a 14 year old daughter implores the naked cyclist at the Fremont Summer Solstice Fair to put a fig leaf on it. 

I have been attending the Fremont Summer Solstice Fair for many years.  I live just a few  blocks away from Fremont, the self designated “Center of the Universe”.  The fair is a fun and funky and freaky celebration of Seattle’s short but wonderful summer and just about anything goes.  But this year, either I’m getting old and cranky or maybe the anything goes has gone too far.

Saturday’s parade has for years included a posse of nude cyclists who seem to appear from nowhere, weave through the parade and crowds and then disappear.  And we all cheer for their naughtiness.   But this year, after the parade, many of the cyclists just hung out, really hung out with nary a loin cloth.  I felt like I was in a urology clinic.  My daughter was having a hard time knowing where to look because everywhere she looked, there was another one.

So dudes, next year make sure you look for me.  I will be the middle aged lady handing out free fig leaves for those of you who forgot yours.

Thanks for reading!  Dr. Lisa Lynn Sowder

Treat acne now to avoid scars later.

If, like me, you are a fan of the cable T.V. show “Justified” you recognize this man as Johnny Crowder.   I find him very attractive despite his really severe acne scarring.  Maybe it’s because he is the quintessential bad boy or maybe it’s because he has such a soft heart despite being a total sociopath.  Anyway, he was killed last season by his even more bad ass cousin, Boyd Crowder so I won’t be able to enjoy his handsome mug anymore.  But this post is not about my taste in men but about acne scars.

Acne is often thought of as just one of the many challenges of adolescence and in many cases it is.  Mild cases can often be controlled with over-the-counter treatments and usually the acne subsides once the hormones have leveled off.  But for some, acne can be a devastating disease.  When the acne lesions are deep and cystic, they can destroy the normal fat layer under the skin and cause deep permanent scars as in David Meunier, the actor who plays Johnny.   Acne scars have not kept Mr. Meunier from  finding success but they may limit his roles somewhat.  He may find himself cast more frequently as a bad guy.

So if you or someone you know has out of control acne, get thee to a dermatologist.  Those pesky “zits” of today can turn into the life long scars of tomorrow.  Oh, one more thing – treating acne scars is really difficult and only partially effective.  It’s much better to prevent them in the first place.

Thanks for reading!  And Johnny, I miss you!  Dr. Lisa Lynn Sowder

Is there an astrologer in the house?

How are those planet lining up for your day of surgery?

Today I saw a lovely lady who is a great candidate for tummy tuck and fat transfer to the breasts.   She’s done with babies, her youngest is out of diapers and she is ready to reclaim a little bit of her babehood.  She’s also got some help lined up and some time off work available and now all she needs to do is check with her astrologer to make sure planetary alignment is just right!

Back when I was a smarty pants young surgeon, I would have dissed this lady’s belief in astrology but now that I have been around the block a time or two, I recognize that many people believe in things that I don’t and vice versa.  So if I need to tweek my schedule a little bit to get in alignment with her planets, I’ll do my best to do so.

Thanks for reading and by the way, I’m an Aries.  That explains everything, huh?  Dr. Lisa Lynn Sowder