A ^Retired Plastic Surgeon's Notebook

Tag: seattle female plastic surgeon


Anatomical versus Round Implants: The study that could never be done was done.

August 4th, 2017 — 10:57am

Can’t tell which side is anatomic and which side is round? Neither can I!

I think the anatomic implants vs. round implants smack down may finally be over.  As those who read my blog know, I am not a huge fan of anatomic implants although I have tried really, really hard to learn to love them over many, many years.  Anatomic implants are presented as the best thing since microwave nachos and those of us who keep going back to round implants are sometimes dismissed as Luddites.  Anatomic implants are pushed by industry paid “experts” who make the rounds at meetings and extol the wonder of these more-expensive-and-more-complicated-than-round implants.  And patients ask for these anatomic implants being lead to believe that they will look more natural.  

A few years ago, evidence started trickling in that anatomic implants actually did not have  advantages over round implants in standard breast augmentation in anatomically normal women. There were studies where before and after photos were shown to expert plastic surgeons and they could not tell which patients had which implants.  I was present at one of these sessions where a panel of experts did no better than a coin toss.  But the study that nobody thought could be done – put an anatomic in one side and a round in the other side on the same patient – has been done!  No patient would sign up for having two differently shaped implants used for her augmentation and no institutional review board would approve such a study.  But some very clever surgeons did this study in 75 volunteers.   Their average age was 39 and their average BMI was 20 (this, by the way, is quite thin).  The surgeons took the patients to the OR and put a round implant in one side and a comparably sized anatomic implant in the other side and then took standardized photographs.  They then removed the anatomic implant and replaced it with a round implant to match the other side.  The standardized photographs were shown to a panel of experts.  Even the panel of experts could not tell the round vs. the anatomic when presented with these side by side breast implants!

I really take my hat off to the Drs. Hidalgo and Weinstein for doing this study.  It is this sort of research that helps us make decisions based on reality rather than the latest hype from an industry hired gun.  

Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation:  A Randomized Controlled Trial.  Hidalgo, David A. M.D.: Weinstein, Andrew L. M.S., Plastic & Reconstructive Surgery:  March 2017, Pages 587-596.

Thanks for reading!  Dr. Lisa Lynn Sowder

 

 

Breast Contouring, Breast Implants, New Technology

Placebo and Nocebo Effect : The Power of Positive and Negative Thinking

February 6th, 2017 — 12:18pm

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.

 

 

Breast Implant Illness, General Health, Now That's a Little Weird, Postoperative Care

Can these procedures be combined?

October 13th, 2016 — 1:05pm

Seattle Plastic Surgeon answers another FAQ.blog-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

My Plastic Surgery Philosophy, Plastic Surgery

HRT and plastic surgery

April 2nd, 2015 — 2:36pm

HRT and Plastic Surgery:  Insight from a menopausal plastic surgeon.blog hot flash

It is well know that hormone replacement therapy can increase the risk of postoperative deep vein thrombosis (DVT).  Some surgeons just recommend to “just stop taking your HRT medication for two weeks before and two weeks after surgery.”   I take a different approach.  “Just stop taking your HRT” means different things to different women.  Some women would just have to put up with a few night sweats but other women (yours truly included) would have a thermo nuclear meltdown.  And adding thermo nuclear meltdown to your list of preoperative and postoperative issues is not very appealing, is it?

My recommendations for women on HRT depends on their menopausal symptoms, their general health and the type of surgery they are having.  In most cases, if a woman has several risk factors for DVT and is one of the thermo nuclear types, I will put keep her on her HRT and put her on Lovenox, a low dose blood thinner for a week after surgery.  Lovenox is injected just under the surface of the skin and, thanks to very friendly packaging and a teeny tiny needle,  even the most squeamish patients and caregivers can inject it.   And, knock on wood, I have yet to see serious bleeding issues with this medication.

Thanks for reading and keep cool.  Dr. Lisa Lynn Sowder

 

My Plastic Surgery Philosophy, Patient Safety, Postoperative Care, Preoperative Care

Are the planets aligned for your surgery?

January 16th, 2015 — 1:12pm

Is there an astrologer in the house?

blog planets alligned

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

Mommy Makeover, Now That's a Little Weird

Why are some breast implants as hard as rocks?

January 13th, 2015 — 11:43am

Calcified breast implant capsules can make a breast rock hard.

KE1

Calcified breast implant capsule surrounding an 32 year old ruptured silicone gel breast implant.

KE2

32 year old ruptured silicone gel breast implant after opening the calcified capsule.

I recently removed  32 year old breast implants from a lovely lady in her mid 60’s.  She was embarrassed how the implants felt when she hugged someone.  “It’s like having two rocks in my bra.”  Here is the reason her breasts felt like rocks.

The photo on the top shows the implant surrounded by the implant capsule.  The photo on the bottom shows the implant (which was ruptured) and the capsule after the capsule was opened.  The yellow gooey stuff is the implant material.  The white structure under the implant is the inside of the capsule.  The white stuff is calcium.  Yes, calcium – the same stuff that makes your bones nice and hard.  The calcium deposits are hard and brittle and can make an encapsulated implant literally rock hard.  Nasty capsules such as this are most common in old silicone gel implants but I have also seen cases like this in saline breast implants.

These photos also illustrate another important point with removal of ruptured breast implants.  In this case, I was able to remove the ruptured implant and the capsule in one tidy piece and there was no spillage of the silicone into the breast.  I love it when I can do this.  It is not always possible but I always try.   When it is not possible and I have to remove the ruptured implant before removing the entire capsule, there is often some spillage but I do my best to minimize it and clean up any spilled silicone prior to closing the breast.

And yet another important point should be obvious from this photo.  Should the capsule be removed along with the implant?  YES!  It would be crazy to leave that nasty capsule behind.  It would shrivel up into a hard mass, be palpable and possibly visible and would look really, really funky on mammogram.   I always go after thick and nasty capsules.  If removing the capsule puts a vital structure at risk, I may leave some of it behind but I try to get as much out as possible.  Removal of the capsule is the hard part of the case but it is worth the effort and time to leave behind a nice, clean breast.

Oh, and one more point.  This were really old implants.  The implants available currently are much tougher and have thicker gel and are less likely to rupture.   The problem illustrated with this case are less likely to occur with the new generation of implants.

And check out my video where I remove a calcified capsule from a saline implant.

Thanks for reading!  Dr. Lisa Lynn Sowder

Breast Implant Removal, Breast Implants

Add a Rash Guard to your summer wardrobe. Your skin will thank you for it.

June 9th, 2014 — 12:06pm

Seattle Plastic Surgeon loves her rash guard.  She also hopes you also have one to love.

cc rash guardI love this time of year in Seattle because the outdoor public swimming pools are open and the lakes are warm enough, barely, for a really quick dip.  And I loooove to swim, especially outdoors.  And I loooove my rash guard which not only protects me from the strong summer sun, it keeps me warm in the chilly waters of Lake Washington and Green Lake and when I am really, really brave, the frigid waters of Puget Sound.

I was a real water dog growing up, spending most of my summer days in Northern Idaho’s Lake Coeur d’Alene or Spokane’s Comstock Pool.  My mother made me wear a t-shirt into to the water in the mid day sun.  As much as I used to gripe about it, I now appreciate her wisdom.  I do have sun damage on my chest and back but it would be much worse without my mom’s nagging.

I have my kids trained so they almost feel a little underdressed without their rash guards.  There’s no need for a baggy, soggy t-shirt to ruin your beach or pool style.  Rash guards come in colors and designs for just about any taste.

Oh, and the lady here is not actually me but I do own this rash guard!

Thanks for reading and happy, happy, happy summer!  Dr. Lisa Lynn Sowder

General Health, Skin Care, sun damage, Wardrobe Observations

A brow lift provides an anatomy lesson in the operating room.

May 22nd, 2014 — 9:13pm

Seattle Plastic Surgeon gives a little anatomy lesson during a brow lift. 

blog anatomy

Leonardo DaVinci loved anatomy as much as surgeons do.

I did an open brow lift yesterday on a lady who had just excellent anatomy.

An open brow lift is done with an incision that is made ear to ear across the scalp about and inch in back of the hair line.  The forehead is then separated from the frontal bone of the skull down to the top of the eye sockets.  (It’s not nearly as gruesome as it sounds.)  There are several important structures in harm’s way so great care must be taken with the dissection.  The rule of surgery is identify it before you cut it (or in this case, don’t cut it) which I think is pretty good advice for everyday living, don’t you?

This lady’s anatomy was right out of a text book.  Her supraorbital nerves that give sensation to the forehead and anterior scalp exited two little holes through the frontal bone  just about the rim of her eye socket.  And the little muscles that allow us to scowl (the corregators) were exactly where they should have been.  I made sure that everyone in the operating room got a good look at this anatomy not just because I find it fascinating no matter how many times I see it, but because it is clinically important.

For example, the entire forehead can be anesthetized with local anesthetic injections into the supraorbital nerves.  This is commonly done for excision of skin cancers on the forehead.  And another example is the corregator muscles.  These are the muscles that are injected with Botox to relax the area and eliminate the scowl.  They are very deep which is why the Botox injection in this area needs to go almost to the frontal bone.

Anyway, it’s a great day in the operating room when the anatomy is so clear.   And, yes, I am easily amused but believe me, the ability to be easily amused is a gift.

Thanks for reading!  Dr. Lisa Lynn Sowder

Now That's Cool, Plastic Surgery, Surgical Eductaion, Uncategorized

Breast Implant Capsular Contracture Revisited

March 27th, 2014 — 3:35pm

Sientra Textured Breast Implants may be an advance in the continuing battle against breast implant capsular contracture.

The breast implant business is a funny one.  Implants come and go and then come back again and then there’s something new that becomes old that is reconsidered or tweeked and then comes back into use and so it goes.  This is why the skeptical Dr. Sowder (that would be me) is skeptical.  But……….I think I might be onto something really, really new and improved in breast implant surgery.  And it’s sort of a new implant shell and gel design.

But the thing that is really, really new is that Sientra, the manufacturer of these implants, is putting their money where their mouth resides.  They are providing a two year warranty for their implants that develop a significant capsular contracture.  Until now, capsular contracture was never covered by warranties.

I recently attended a presentation regarding these newish implants and asked the CEO of the company how Sientra can possibly offer a warranty for a problem that has plagued breast implants from day one and is considered almost an act of God by those of us who do everything in our power to prevent capsular contracture.  blog sientra

Here is what may be different with implants manufactured by Sientra.

1.  Sientra textured implants have a different surface configuration that seems to allow more integration into the surrounding breast meaning that it does not scream “foreign body!” quite as loudly as a smooth implant or implants with other types of texturing.  It is the foreign body response that accounts for capsule formation.

2.  The Sientra implant cohesive gel is really, really adherent to the implant shell.  The shell cannot be torn off the gel.  The gel just sticks to the shell, even with strong traction.   So even if there is a tear or fracture in the shell, the shell and gel just hang together and the gel does not extrude outside the implant and possibly set up and inflammatory reaction leading to thickening or tightening of the implant capsule which is what causes capsular contracture.

3.  Sientra only sells its breast implants to surgeons who are certified by the American Board of Plastic Surgery, a.k.a. Real Meal Deal Plastic Surgeons (me, for example).  Sientra feels that those of us who have put in the years and years of training in plastic surgery do it better than those who have come to do cosmetic breast surgery via the back door.  This is not the case with the other two manufacturers of breast implants in the United States.

Sooooo…………. I am now offering Sientra implants for breast augmentation.  All the warranty paperwork is filled out by our office and every Sientra patient is automatically enrolled in the warranty program.  And if I never see another capsular contracture in my life…………….

Thanks for reading.  Oh, and Sientra doesn’t pay me to say nice things about them but they did feed me the other night at the dinner presentation but I only had one glass of wine and I skipped dessert.  Dr. Lisa Lynn Sowder

 

 

 

Breast Contouring, Breast Implants, New Technology

Keep those fresh scars out of the sun!

September 5th, 2012 — 11:30am

Seattle Plastic Surgeon discusses the importance of keeping fresh scars out of the sun.

This ankle scar would have turned out much better had it been protected from the sun.

Seattle is enjoying a beautiful late summer with warm, sunny days and crisp and cool nights.  There’s lots of skin showing out on Seattle streets and I am compelled to nag a little (again, for the bazillionth time) about sun protection.

Fresh scars are very susceptible to the sun and can turn permanently dark unless protected.  A “fresh” scar is defined as any scar that is still pink.  A “mature” scar is defined as any scar that is soft, flat and normal skin color or a little lighter.  Most adults have a “mature” scar by about a year.  Childrens’ scars may take longer to “mature”. 

 The best way, in my opinion, to keep a “fresh” scar protected is to cover it with clothing or with a piece of flesh colored tape or, if you prefer, a Hello Kitty band aid.  Really good sunblock will also likely do the trick if you remember to reapply it several times during the day.   Keep that scar protected until it fades to normal skin color or lighter and then sun exposure is unlikely to cause it to hyperpigment.

 A dark scar may be helped with hydroquinone cream or laser or surgical scar revision.  But, as per usual, an ounce of prevention is worth a pound (and $$$) of cure.

 Thanks for reading!  Dr. Lisa Lynn Sowder

Plastic Surgery, Postoperative Care, Scar, Skin Care, sun damage

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