A ^Retired Plastic Surgeon's Notebook

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.

Seattle gynecomastia patient shows what can happen once a guy is comfortable going to the gym.  It’s a beautiful thing.

Top: Before surgery and some serious gym time. Bottom: After surgery and some serious gym time.

I find it very gratifying to help patients achieve their personal best through plastic surgery.  And I find it super gratifying when plastic surgery really helps a patient make a commitment to better self care.

This patient is a middle-aged guy who felt embarrassed about his pudgy chest.  He has a mild case of gynecomastia but a serious case of self consciousness.  I performed a  gynecomastia reduction on him.  I used my standard technique in this type of gynecomastia.  I removed the excess fat from his chest with power assisted tumescence liposuction and excised the little bit of excess glandular tissue though an incision under his nipple.  This technique leaves teen tiny scars that are almost imperceptible.  I am always careful to preserve a disc of breast tissue under the nipple.  This keeps the nipple from caving in.

He was well-enough healed at about 3 weeks to start  going to the gym for some weight training and before long, he was feeling really, really good about his chest.   Not all of my patients get this inspired but I sure love it when they do.  They provide me with some really, really nice before and after photos!

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon is a little bit offended by the Physician Payment Sunshine Act but then again she is quite the Girl Scout and not easily bribed.  And where is the Congressional Payment Sunshine Act?

Sunshine is an excellent disinfectant. Could we get it to shine a little on our politicians?????

The Physican Payment Sunshine Act is a nearly 300 page document about to land on the desk of doctors.  It is part of the Obama administrations ACA and is meant to keep those of us in the  medical industrial complex honest.

I must be living under a rock but apparently we doctors have been bought by the pharmaceutical and medical device companies who apparently make it a practice to shower us with fancy trips and meals and golf outings and all the pens and pocket protectors a doctor would ever need.  And all of this bribery makes us doctors prescribe drugs and use devices for patients that we otherwise would not.   Say what???????????

Maybe my memory is failing me but I just cannot think of an incident where I have used a medication or a device that I did not think was in the best interest of my patient.

I, like most doctors, do attend seminars and workshops and even anatomic cadaver labs to learn about new products and devices and how to use them and, yes, the sponsoring companies do feed us if  these events occur at mealtime.  Maybe we are just going to have to start brown bagging it lest we be overly influenced by all those Subway Sandwiches and Diet Cokes.

Sorry to sound so cranky but I’m just wondering when the sun is going to shine on those who are shining it on me.  I think they need a little cleaning up too.

Thanks for reading.  Dr. Lisa Lynn Sowder

Seattle Plastic surgeon teaches patients to visualize liposuction volumes and weights using butter.

One pound of butter = one pound of fat.

One of the most frequently asked questions in my office is “how much fat will you remove?”  The answer usually ranges somewhere between 1 – 10 pounds.

So how much is 1 – 10 pounds?  This can be hard to visualize.  I recommend thinking of excess fat as sticks of butter.  One stick of butter is 1/4 of a pound.  A box of butter – 4 sticks- is 1 pound.  Ten  boxes of butter – 40 sticks – is 10 pounds.  That’s a lot of butter and a lot of fat!

Liposuction results in targeted weight loss which is why liposuction is so useful in patients with uneven fat distribution – think of the lady with a narrow waist but heavy thighs.  She would have to starve herself to see much slimming of her thighs.  Liposuction could remove several pounds – think several boxes of butter – of fat from each thigh.

Liposuction is not so useful in patients who are significantly overweight all over.   It is not possible to safely remove an extra thirty pounds with liposuction.  That weight needs to be lost through lifestyle changes.   Once a healthier weight is reached and if there are still areas of recalcitrant fat, then liposuction will likely be indicated.

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon is very, very grateful that she does not have a desk job.

Earlier this week I had one of those crazy days at work.  I did a 5 hour operation followed by a 2 hour operation followed by a 1/2 hour office procedure followed by a couple of follow-up patients.  I was tired inside and out by the time I finally sat down to dinner with the famn damily. 

The next day, right there in the Wall Street Journal was this article about how sitting too much can kill.  That right, k-k-k-k-kill.  It made me think about how much I am up and running around really every day, whether  at work or at home.   Part of this is just my hyperactive nature and part of it is in the job description. 

Soooooo, if you have a desk job, think of ways you can get off your duff frequently.  In our office, even those employees who have desk jobs are always up and about, either looking for a patient chart or interacting with patients and other staff. 

If you are sitting too much, consider scheduling some “up time” into your day or even consider getting a standing desk or, if your office allows, an exercise ball to sit on.  Do whatever you can to KEEP MOVING.

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon blogs about predicting patient satisfaction following liposuction.

Later this month, I am giving a talk to the Washington Society of Plastic Surgeons on Plastic Surgery and the Overweight or Obese Patient.  This is a very prickly topic and a difficult one to discuss, especially with the overweight or obese patient.  I do my best to be straight forward and honest about what body contouring can accomplish in this patient population and try to educate patients about realistic expectations.

While researching this topic, I came across this very helpful diagram.  This was published by Dr. Rod Rohrich and associates at the University of Texas Southwestern.  They looked at the effect of post liposuction weight changes on long term satisfaction .  They came up with this very helpful chart.  I am going to start using this chart for all my body contouring patients, regardless of their weight.

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic surgeon offers help for a common problem – ARMPIT CLEAVAGE

Most women have a little bit of breast tissue and fat just in front of the arm pit.  This is called the axillary tail of the breast.    This is all normal.

But some ladies, even slender ladies, have more than a little bit of breast tissue and fat in this area and I have heard it called many thing;  armpit cleavage, pit boobs, waddies, etc.  Whatever you want to call it, it can be an annoyance especially with some type of clothing.

The good news is that it is usually treatable with liposuction and this can usually be done at the same time as another breast procedure .   The excess fat and tissue is quite fibrous and therefore  a little tough to suction out.  Also, this area stays firm and sometimes lumpy for several months.  But when it’s all done and the swelling is down and the tissues softened up, it can be a really, really nice improvement.

I occasionally have to actually excise the area if it is quite large or saggy.  That incision is usually pretty easy to tuck up in the underarm area and it usually heals with a thin white line.

So if you have this annoying problem, I’m here to help.  If you get you surgery done by St. Patrick’s Day, you will be more than ready for summer clothes by Summer Solstice.

Take a look at this patient below.  She had a periareolar breast lift to lift her nipple and improve the shape of her breasts and also liposuction of her armpit cleavage.  She is shown about 3 months after surgery with a nice result.  She’ll look even better at six months as her scar around her areola fades.

Thanks for reading!  Dr. Lisa Lynn Sowder

This patient wants her nipples lifted a little and the shape of her breast improved with the least possible surgery. She also wants to get rid of her armpit cleavange.

Here she is 3 months after a periareolar lift and liposuction of her armpit cleavage. She only took a couple of days off of work. She's pleased with her result as am I.

Permanent weight loss – here’s what I’ve learned from my patients

How to lose weight for good according to Dr. Lisa Lynn Sowder’s weight loss patients.

I am a bit of an expert on weight loss, not because I have ever had major weight loss, but because I know so many patients who have and have been able to maintain their weight loss.  These are patients who come to me for body contouring procedures such as abdominoplasty, breast lift, upper arm lift, thigh lift, flank lift, lower body lift and so forth.   

I always ask them how they managed to finally lose the weight and keep it off.   I ask them to go into some detail.  This is not because because I want to write the next “diet bestseller” and buy a small island in Greece (although that would be nice) but because I want to pass on their secrets of success to other patients who struggle.

 About 40% of my weight loss patients have undergone weight loss surgery.  That’s another blog.  The other 60% have done it through life style changes. Here is what that 60% have told me:

• Without exception, they have all sworn off sweets and refined carbohydrates.
• Many have embraced a very low carb diet – think Adkins  diet.
• Almost all have maintained regular aerobic exercise – walking and biking are the most popular with my patients.
• Many of my patients have been helped with support groups such as Overeaters Anonymous, TOPS, and Weight Watchers.
• A few of my patients have been helped with nutritional guidance from a physician or nutritionist.
• I cannot remember a patient who mentioned a prepackaged food or liquid diet system. 

And here are a few patients I will never forget:

• One gentleman lost 60 pounds when he quit drinking with the help of Alcoholics Anonymous.
• One lady was able to stay 180 pounds overweight despite her gastric bypass through continuous and careful overeating.  She finally dropped her weight 150 pounds when she addressed her emotional issues with a psychologist and the help of Overeaters Anonymous.
• One lady lost over 100 pounds by jogging.  She started really, really slow and got faster and faster as she lost weight.   She became addicted to a runners high which I guess is better than most addictions.
• Several of my patients were able to slim down only after leaving a dysfunctional relationship.
• One teenager lost 40 pounds just by giving up soda.
• One lady in her 60’s lost 100 pounds after having bilateral knee replacements.  She had been very, very sendentary and once pain free,  became more active.

So there you have it folks; Dr. Sowder’s  Guide to Slow, Deliberate, Difficult, Soul Searching, Sweating, Hungry but Long Term Weight Loss.    Just think, I could have written that best seller and here I am just giving it away.

Thanks for reading.  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon, Dr. Lisa Lynn Sowder blogs about patient satisfaction. 

I can usually tell when a patient really, really likes the result of their breast or body contouring surgery, at least if they have had any sun lately.  I just take a look at their tan lines!  (Those of you who read this blog regularly know that I am totally anti-tan and I am not advocating any activity that causes tan line nor do I advocate non-tan line nude sunbathing!)

Sometimes I’ll have a patient who is super picky about a very minor imperfection but who has tan lines that tell me he/she is comfortable not wearing much at the beach or pool.   Once I had a tummy tuck patient, well into her 50s, that was upset that her string bikini didn’t cover her bikini line scar.  That is what I call a happy problem!

Hey, thanks for reading and stay away from those tanning beds.  More on that in an upcoming blog.  Dr. Lisa Lynn Sowder