It’s that time of year again. Roll up your sleeve and get your flu shot already. Why should a “surgical sub-specialist” like me care about whether or not you’ve had your flu shot? First of all, I’m a physician and it is my duty promote good health. Second of all, I don’t want any of my patients coming down with the flu. If a patient falls sick before surgery, we have to cancel and then reschedule the case which is hard on us meaning surgeons, anesthesiologists, surgical techs and nurses and it is also really hard on the patient because he/she has to carve more time out of a busy schedule and many times arrange for child care, not only for surgery but for recovery.
If a patient comes down with the flu in the early postoperative period, he/she may end up wishing they had never been born. That would make for a less than excellent plastic surgery experience and could also be down right dangerous.
And we tend to think of the flu as just an inconvenience with a little misery added but really, the flu can be very, very serious. I am old enough to remember the Hong Kong Flu of 1968. I was sicker than a dog and missed a week of school but was not one of unlucky million or so who died. And then there was a Spanish Flu of 1918 that killed 50 (!) million mostly healthy, young people. Sorry to be such a fear monger but I really want you to get a flu shot.
Seattle Plastic Surgeon blogs about fillers she does not like and does not use.
I’ve written many blogs on the miracles of fillers for facial aging. I think they are the best thing for facial maintenance since sunscreen.
Facial silicone gone bad. Really, really bad.
The fillers I really like and use a lot are Voluma, Juvederm, Restylane, and Perlane which are all hyaluronic acid (HA) fillers. The thing I love about HA fillers is their ease of use, safety, and their reversibility when a rare patient (1 every five years or so) does not like the result. The HA fillers can be reversed by injecting an enzyme which dissolves the filler within 24 hours.
I also use fat as a facial filler in some cases. The thing I like about fat is that there is usually an abundant supply and it is often very, very long lasting and sometimes permanent.
There are other fillers out there. Here’s my list of fillers that I just don’t like or use. Full disclosure here: this is based solely on my (sometimes very limited) experience, hearsay, prejudice and my risk adverse nature. Some of my colleagues use these regularly and successfully but these fillers just give me the creeps.
Collagen: It is sooooo yesteryear. Even when it was the only legit filler out there, I didn’t like it. Patients needed a skin test 30 days prior to using Collagen. The results were fleeting and even a detail freak like me had trouble getting a nice smooth result. Oh, it also had to be refrigerated and shelf life was very limited. Oh, one more thing, it comes from cows.
Radiesse: This is used quite a bit in the Seattle area but it gives me the creeps. It’s made of teeny, tiny spheres of calcium hydroxylapatite and provides a scaffold for connective tissue growth. It is quite thick and can fill in deep creases nicely but can also result in nodule formation. Radiesse lasts 1 -2 years which is great (unless you are one of the unlucky ones who develops nodules). I used it a few times years ago in a a few employees who volunteered (really, they did) to be my training subjects. All three of them bruised really, really badly and I felt like a worm until their bruising resolved. I don’t have a cajones to try it again.
ArteFill: Yikes. This is a scary one. This is a permanent filler which is made up of teeny, tiny spheres of polymethylmethacrylate. They elicit a “foreign body response” which walls off the little spheres with collagen. It also requires a skin test 30 days before injection because the sphere are carried in liquid collagen. My training subjects this time were two pals of mine. Both had negative skin tests. My first patient did fine and is still my pal. The second patient, who was from out of state, had to delay her injection because a family illness prevented her from traveling. Four months later, she had a rip-roaring inflammatory reaction to the little spot on her forearm where I had injected the test dose. It was by the grace of a good and loving God I had not injected her face. She is still one of my very best pals. I have also seen many case reports and a couple of patients with poor results from ArteFill. The only way to get rid of it is to surgically remove it.
Sculptra: Sculptra stimulates dermal fibrosis and thickens the skin. This is filler was first introduced about 10 years ago for use in patients with HIV. The medications that many HIV patients rely upon to stay healthy have the side effect of facial wasting. This filler is made of poly-L-lactic acid, the same chemical that a common suture, Vicryl, is made of. I use Vicryl a lot. It is easy to sew with. It provides strength and support for a couple of months while an incision heals and then the body absorbs sit. But once in awhile, a patient has an inflammatory reaction to the suture. I have had maybe a dozen patients over 20 + years of practice who have “spit” every single stitch. There are many case reports of disfiguring inflammatory reactions to Sculptra and all I have to do is think of one of my Vicryl “allergic” patients and I break out into a cold sweat. Am I a wimp or what?
Silicone: This is the Queen Mother of Bad Fillers (in my humble opinion). It has been used for decades and is responsible for the permanent disfiguration of many, many patients. I will never forget a lecture I attended when I was a surgery resident on the treatment of a bizarre condition called Romberg’s disease. This disease causes profound atrophy of facial fat. Way back when, these patients were injected with medical grade silicone and initially it was beneficial. But fast forward 10, 20 even 30 years and many of these patients went on to develop severe inflammatory reactions that were more disfiguring than the original disease. I know of a plastic surgeon in Hawaii who used this stuff on his wife’s lips. Yikes.
So there is my personal rogue gallery of “no thanks” fillers. All of these (I think) are still in the good graces of the F.D.A. but you won’t find them on my shelf.
Hey, thanks for reading. That was a slog, wasn’t it? Dr. Lisa Lynn Sowder
Seattle Plastic Surgeon implores patients not to fall for “Botox on Sale”.
Occasionally I have patients come in for Botox or fillers who have flitted around from doctor to doctor looking for the “best price”. I hear statements like “the last Botox didn’t work” , “the Restylane didn’t last”, “I’m not sure what she used but I didn’t like it”, and this is my favorite, “it was on sale but it didn’t last”.
This flitting around in search of a “deal” makes it very hard for a hardworking plastic surgeon (moi, for example) to figure out what, where and how much injectable to inject. In my practice, we keep very accurate records of all of the above so I can judge what works best for any given patient. And believe me, every patient is different.
Sometimes I think just because it is “cosmetic”, patients don’t take these treatments seriously enough. I cannot imagine anyone shopping around for the “best” price on, say, steroid injections into a bum shoulder or the “best” price for an hour of psychotherapy!
Usually continuity of care provides the best value of all, even if the prices are not bargain basement. So for injectables, find a good doctor and stick (nice pun, huh?) with him/her.
Thanks for reading and follow me on Instagram @sowdermd and @breastimplantsanity. Dr. Lisa Lynn Sowder
Seattle Plastic Surgeon (and mother of three) Dr. Lisa Lynn Sowder you about lawn mower safety.
It was such a wonderful thing to get some yard work out of my offspring once that they were old enough to mow, rake, sweep, weed, water, trim, edge, poop scoop, etc. As much as I loved the smell of newly mown grass and the thought of them working (instead of me), I worried. I worried about the lawn mower thus the little nag session each and every time one of my boys was nagged into mowing the lawn.
Here is my list of lawn mower safety tips.
Only children over 13 should mow a lawn.
One person only should be on the lawn being mowed. That would be the person behind or on the mower.
NO PETS unless it’s a rabbit you really wish you had never adopted.
Always wear socks and heavy shoes and gloves.
Always wear eye protection.
Ear plugs okay but not earbuds for listening to Bad Bunny’s greatest hits. They need to hear you yell, “Watch out for the dog!”
No mowing until the offspring has cooled down from his/her rage at having to actually perform agreed upon chores for agreed upon bennies. Rage and lawn mowers should never coexist.
If the mower malfunctions, turn it off and don’t even think about flipping it over unless a knowledgeable and responsible adult is present.
Leave sharpening to the experts. Oh, unless you work in a lawn mover sharpening shop, you are not an expert.
No using the lawn mover for anything other than mowing the lawn. This calls for a cautionary tale: Two patients in the same day present with nearly identical lawn mower injuries sustained while attempting to trim a hedge with a lawn mower. Patient #2 happen to see patient #1 (prior to his mishap) trimming his hedge with the lawn mower while Patient #2 was driving to get gas for his lawn mower and thought “Hey, what a great idea.” Not. This cautionary tale was told to me by an esteemed colleague practicing in Spokane, Washington many years ago. Being Spokane born and raised, I have every reason to believe it is 100% true.
Stay tuned. One of these blogs I will tell you about my dad’s snowblower injury. His bloody glove is still nailed to the wall of his shop some 30 years later.
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.
This is an ABC news report written by Serena Marsh and edited for length by me. This was originally posted in 2012.
Sunny Side Old: Pic Reveals Sun’s Aging Effects
William (Bill) Edward McElligott is two different ages, 66 and 86 yeaars old.
If you look at McElligott from the right, he looks like any 66-year-old would expect to, but from the left, wrinkles and sagging skin place him far beyond his years. He is a living demonstration of the importance of protecting your skin from the sun.
“It would take me an hour to drive to work and an hour to come home,” McElligott said. “It was a semi route, I’d have six to eight stops. … 6 a.m. to 3 p.m. on the road.”
For almost 30 years, McElligott drove a truck during prime sun hours throughout the city of Chicago delivering milk to stores and gas stations.
“My left arm was always more tan than my right, because a lot of the time I had the window open (since) we didn’t have A.C.,” McElligott said.
The 66-year-old truck driver suffers from unilateral dermatoheliosis or photo-aging, which was caused by repeated, long-term exposure to UVA rays of the sun.
It was 15 years before he noticed any difference between the two sides of his face, but McElligott ignored it, that is until his grandchildren’s questions got the best of him.
Dr. Jennifer Gordon a dermatology resident at UT Southwestern saw McElligott while on a rotation at Northwestern in Chicago and submitted his case study, which was featured in the April edition of the New England Journal of Medicine.
“It was very stark,” Gordon said. “We are used to seeing photo damage, photo aging every day, (but) for it to be so one sided? We were taken aback.”
Gordon explained that since McElligott spent so much time in his car, his left side was exposed to UVA rays that can penetrate glass and cause the majority of photo-aging, unlike UVB rays, which cause sunburns.
“We think its because it (UVA) can penetrate more deeply into the skin than UVB and affect your collagen and elasticity,” she said. “When you destroy those that’s what gives you the aging appearance that we see.”
Dr. Mitchell Chasin, a dermatologist who did not treat McElligott, says it is extremely common to see patients that come in with more damage to their left side than their right.
“Most people are completely unaware and most people who come in to have sun damage treated, they often times will point to their left side saying they see more spots, more wrinkles, more aging, but never put two and two together,” said Chasin.
Chasin says that whenever people are outdoors, even when covered from the sun directly or on a cloudy day, they should be aware they are not safe from the reflected rays of the sun and should wear sunscreen.
“Sun block is the answer, really, for someone 365 days a year, whether it’s cloudy whether it’s sunny, whether someone is outdoors, in the car, or at the beach,” Chasin said. “If someone wants to age as best they can, sun protection is a daily regimen no matter what you are doing. Put sun block on before you leave the house.”
With summer approaching and vacations and road trips, it’s important to make sure your sunblock has protection against both UVA and UVB rays.
Last year the FDA demanded sunscreen manufacturers update their labels to offer protection for both UVA and UVB, as well as to stop the use of misleading claims such as waterproof. The agency recently extended the deadline to December for manufacturers to comply.
For McElligott sunscreen with UVA and UVB protection has become a daily fixture.
“When I’m out in the sun, when I’m going to be driving, I have sunscreen on,” he said. “I always carry it with me.”
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.
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 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.
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.
@lisalynnsowder
