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.

Seattle Plastic Surgeon Discusses Mommy Makeover on Mother’s Day

Ah, the joys of motherhood! I can wax eloquently about fat little feet, apple cheeks, wet baby kisses and so on but one of the joys I did not expect was a boost in my Plastic Surgery practice, especially my “mommy makeover” patients. Since becoming a mother myself, I speak “mommy” really well. I know first hand the glorious details of feeding, bathing, changing, and schlepping the baby. I can recite the stages of the toddler, the preschooler, the gradeschooler, the tween, the teenager and currently I am becoming an expert on the joys of being the mother of young adults.  

Being familiar with all that being a mother requires makes me much better at counseling patients about the process and timing of a “mommy makeover”.

“Mommy makeovers” usually combine breast surgery (augmentation and/or lift or reduction) with body surgery (usually abdominoplasty and/or liposuction). Most women are healthy enough to have a combination of procedures during one operative session. It is, however, the first couple of post operative weeks that are the most challenging for the patient.

Mommy is used to taking care of everyone but herself. After surgery the Mommy needs to take of only herself. She needs to be “Queen for a Week or Two” and resist the urge to cook, clean, change, wipe, mop, vacuum, load, unload, fold, etc. And if her youngest weighs over 20 pounds, she may not pick him/her up for at least two weeks if breast surgery was done and for at least six weeks if an abdominoplasty was done. The little one can crawl into Mommy’s lap for a cuddle but NO HEAVY LIFTING for Mommy. This also applies to the dog.

It’s very important to for patients to discuss these issues with their families. I’ve had a few ladies who have underestimated their recovery time, have done too much too soon and have turned what should be a relatively comfortable and relaxing recovery into a very sore and frustrating one.

So, calling all mothers interested in a “mommy makeover”: Plan ahead and get your husband and your children and your friends on board. Make a sign for your bedroom door. “DO NOT DISTURB – MOMMY RECOVERING”.

Seattle Plastic Surgeon knows how to make the Grinch look a little less grinchy.

It’s those glabellar frown lines and nasolabial folds that make this Grinch look soooo grinchy.

Take a look at the Grinch.  What is it that makes him look so old and cranky?  It’s his glabellar from lines between his eyes that make him look like he’s having a pretty bad day and it’s his nasolabial folds (those creases that go from the sides of the nose to the corners of the mouth) that make him look a billion years old. All he needs to do to work himself up into a really bad mood is to look in the mirror every morning.  No wonder he has such a bad attitude.

If the Grinch were to come into my office, here is what I would recommend:

His forehead creases would be softened and smoothed out with Botox.  He looks like he needs a pretty large dose, maybe 60 units.  The injection would sting but would be quick and he would see a remarkable improvement within 3 days or so.  Also, he would feel so much more relaxed.  If he wanted to scowl at his poor little dog, he would be unable to!  Smile, yes but scowl, no.  This amount of Botox would set him back $900 and would last at least 3 months.  If he kept coming back for treatment, his dose would likely drop considerably.

His nasolabial folds could be filled in with one of the hyaluronic facial fillers that I inject almost every day of the week.  They are terrific for treating the area around the mouth that is such a problem in some people and is hard to treat with other methods.  Even a full face lift doesn’t help this area very much.  I would use 2 or 3 syringes to get as full of correction as possible.  It’s been my experience that patients who opt for just partial correction (to keep the cost down) are not nearly as satisfied as those who just go for it.  Three syringes of a filler such as Juvederm would set him back about $1600.  Juvederm lasts at least six months and I have many patients who have had nice lasting improvement for up to two years.

Do what about the redemption of his rotten soul?  I’ll leave that up to the transcendent love and forgiveness of Whoville. But he’s got to save his face for me.

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

Resusianne saved once again by Seattle Plastic Surgeon. 

Last Saturday I had my biyearly Advanced Cardiac Life Support review and examination.  After an excellent review of heart rhythms, various resuscitation drugs,  much studying and fretting and sweating bullets while taking the written exam, I was taken into a small room by a seasoned and tough-as-nails intensive care unit nurse.  There, on the table, lay Resusianne.  After many years of saving her life, I just call her Anne for short.  I don’t really care for her much but only because she makes me so nervous.  You see, she is always trying to die on me.

Resusianne lives yet again.

My nurse examiner starts with the scenario that I’m in Nordstrom’s and come across a woman who is laying, unmoving on the floor.  My first thought is sticker shock at the price of this bikini but I keep that to myself.  I automatically go though the drill that has been beat into me over three decades.

“Anne! Anne! Are you okay?”  Of course she’s not okay.  Resusianne is never okay but it seems polite to ask.  “I need help!  Someone call 911 and someone bring an AED.”  And then I start CPR.  Now the fun starts when the AED arrives.  I have to fumble for the on switch, rip open Anne’s shirt (fun!) and put on the paddles and then start CPR again until the AED tells me to stop.  And then it seems like an hour before the AED decides to shock Anne.  As soon as the shock is completed, I start in on CPR again until the nurse has mercy on me and tells me I can stop.  Good CPR is really, really physical, especially for a petite little gal like me.  By this time, I am a nervous wreck.  I take Anne’s problems way too personally.

Normal Sinus Rhythm is a beautiful thing.

Next, my examiner gives me this scenario:  I’m in the operating room with a patient and her EKG shows a heart rate that suddenly goes from 68 to 135 and her blood pressure starts to drop.  This is the arrhythmia part of the test.  You know that nice normal EKG pattern we always see with a spike between two humps? That is called normal sinus rhythm and that is what we love to see on an EKG but Anne is such a drama queen.  She’s never in that rhythm for long.  There are a dozen or so aberrant rhythms that range from kind of ugly to downright terrifying.  Her current rhythm is somewhere in the middle and responds to a nice dose of Adenosine.  She converts to normal sinus rhythm.  Woo Hoo!   But there she goes again.  Fie on her.  I give her a second and larger dose of Adenosine which really works this time.  After Anne is conscious, I tell her that I will never, ever operate on her again and that she needs to find another plastic surgeon with larger cajones than mine.

And then my examiner raises the bar.  This time Anne has just walked into my office to get her tummy tuck stitches out and she goes to ground right in the middle of my really nice waiting room!  How rude.  I go through all the steps of CPR and get EKG monitoring set up  which shows normal sinus rhythm but Anne has no, nada, zero, zilch pulse.  So now while I’m doing CPR and getting an IV started and pushing epinephrine I have to figure out why it is that Anne’s heart has electrical activity but is not pumping blood.  There are about 12 reasons this can happen and I start with the most common in this scenario which is a pulmonary embolus (a blood clot to the lung).  Now, after some IV fluid and epinephrine,  Anne has a little bit of a blood pressure and I am ready to inset a breathing tube and get her over to Swedish Hospital for a diagnostic CAT scan and treatment and I’m about to have a cardiac arrest myself with my nurse examiner tells me that my exam is over and I passed!   WOO HOO!  I’m good for two more years and now I get to go change my scrubs which are soaked with sweat.  I really, really hope I never have to use these skills.  But I’m glad to keep up to date …..just in case.  I say goodbye to the examiner but not to Anne.  I may have a different examiner in two years but I know Anne will be back.  She always is.

Thanks for reading and if you don’t know CPR, get thee to a class.  The life you save my be of someone you love!  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

These arms are NOT the result of plastic surgery!

Seattle Plastic Surgeon discusses options for upper arms.

The thermometer in Seattle is finally hitting 70 degrees after the most wretched sping in recorded weather history and I’m getting a lot of questions about upper arm enhancement.

The First Lady’s arms are the result of good arm genes and a great personal trainer.  Also, she has not yet entered the menopausal years (more about that in a future post).  For those without Mrs. Obama’s genes or trainer, there are a few procedures that can be done to improve the upper arm.  Which procedure is the most appropriate is dictated by several factors:

• Skin tone
• Thickness of the fat layer
• Condition of the underlying muscles
• Scar history

Patients with a thin layer of fat and poor skin tone are usually older and thin.  The only procedure that will improve the upper arm is a brachioplasty.  This procedure involves removing the excess skin of the upper and inner arm.  This always leaves a scar from the axilla (arm pit) to the elbow.  I strive to keep this scar on the surface that is hidden against the side when the arms are down.  The question patients must ask them selves is: “Am I willing to trade these bat wings for a scar?”  In patients who heal well and the scar is narrow and light, the answer is usually “yes” but I do have one brachioplasty patient who has a lovely arm shape and excellent scars who is still too self-conscious to go sleeveless.  I may have hit a surgical home run with her but I don’t consider the case a complete success.

Patients with chubby upper arms and good skin tone are great candidates for the CAST procedure.  This procedure involves circumferential treatment of the arm with very careful tumescense power- assisted liposuction.  The fat removal is limited to the outer arm where the excess fat resides but the inner arm is also treated with undermining the skin with the blunt liposuction cannula off of suction to stimulate shrinkage and tightening of the skin.  Patients wear a compression bolero to help the skin tighten postoperatively.

Patients who are “in between” are often candidates for a combination procedure where the incision and resultant scar can be confined to the axilla and the very, very upper inner arm where the sun hardly ever shines.

So if you want perfect Mrs. Obabma’s arms, sorry it’s not likely to happen.   But is you want better arms, there is likely something I can do to get you to your personal best.

Thanks for reading!

Seattle Plastic Surgeon, Lisa Lynn Sowder, M.D.