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Constructive Skepticism- Case In Point: Liposuction Breast Reduction Throughout my training I was cautioned that the most dangerous times for a patient to undergo a surgical procedure were the first week in July, when new residents were beginning their training, and any week after a major conference, when surgeons were attempting the best and latest techniques. With regard to the editorial Listen Carefully, But Adopt Skeptically (Plast. Reconstr. Surg. 109: 2065, 2002), I completely agree with Dr. Puckett that there is a palpable trend in plastic surgery for speakers to sell their operations, and the pivot point for the sale often hinges on scars and their reduction. Having trained and practiced with Dr. Melvin Spira, I am well versed with his maxim of Function over Form and Form over Scar. Patients will usually tolerate whatever form we need to give them if it will improve their functional ability. A person will gladly replace a lost thumb with a toe-to-thumb transfer, even if it leads to a loss of form at the foot and a noticeable difference on the hand. Similarly, regarding Form over Scar-a woman will easily accept a longer lateral abdominoplasty scar in place of the poor form of a dog-ear. I agree with the author that many of the myriad procedures of the breast, abdomen, and face, which tout shorter or minimal scars, are often performed at the expense of better form. I must, however, disagree with the author's specific assertions on liposuction breast reduction. The history of breast reduction is surgical. Over the past century, breast reduction has been modified and improved many times, but always within a surgical paradigm. Many of the improvements were functional, providing greater viability to the nipple-areola complex, whereas others were in form, providing projection and contour. Historically, however, these latter changes in form were based on plastic surgeons' perceptions of what the female breast should look like and our application of those perceptions to our surgical technique. No one asked reduction patients what they wanted; we only studied the optimal breast and attempted to copy that form. I contend that in the case of breast reduction, the concept of Form over Scar does not necessarily apply. We must be honest with ourselves. The primary reason for reduction mammaplasty is, as the name suggests, reduction. The technique of liposuction currently allows us to move past the last century's surgical paradigms. It allows us to remove the breast weight that our patients complain about at a fraction of the recovery time, expense, and scar. It also exposes the operation to a tremendous number of women who would never have otherwise considered reduction. Although the author mentions that his patients do not mind the scar, they are a self-selected group of individuals who have accepted the surgical-reduction concept and sought his care. I believe that for each of these patients, there are many others who did not seek a plastic surgeon's help because they did not want the scars or could not afford the time away from home to recover from a traditional reduction. I am also amazed at how many women I see in my office who could not care less about nipple position. They just want the weight reduced. This concept surprised me at first, but when I realized that it was the plastic surgery community that decided how the reduction mammaplasty procedure was to be done, and that we were limited to a strictly surgical technique, I realized that we were doing the best we could. We should now be expanding our horizons and looking at those procedures that will benefit our patients in all ways. I believe that the liposuction breast reduction is one of those procedures. If plastic surgeons do not carefully examine the liposuction breast reduction we may not only be underserving our patients, but we may also be writing our own epitaph in breast reduction surgery. This operation perfectly separates the functional (and insurable) portion of the procedure from the form (insurance-deniable) segment. Because breast reduction is aimed at reducing breast weight, it is only a short matter of time before insurance carriers realize that breast reductions can be performed as an outpatient procedure at a fraction of the cost and recovery time of a traditional surgical procedure. In a few years liposuction breast reduction will be the only type of reduction procedure reimbursed by insurance companies. Many other specialties are already putting their names on this procedure, and I believe that it would be a loss to plastic surgery if we lost this operation because we did not examine it carefully enough. I have the utmost respect for Dr. Puckett. After all, he is certainly one of the names in plastic surgery that he mentions in his editorial. His wise words of caution when approaching new procedures are pearls of wisdom harvested from a rich plastic surgical career. I do hope, however, that he and others in the field look carefully at liposuction breast reduction as a potential plastic surgical tool and give it the study and consideration that it deserves. Martin Moskovitz, M.D.
The idea of using liposuction to harvest fat and then inject that fat into the breast has been around for decades and many patients who come in for liposuction ask “Can’t you take it form here (the butt), and put it here (the breast)?”. The American Society of Plastic Surgeons issued a position paper on fat injection to the breasts in 1989 and disapproved of the procedure primarily because of the effects it could have on breast cancer surveillance and mammography. A recent article in Plastic and Reconstructive Surgery did, however, show impressive results in several breast augmentation patients using only fat injection. There are, of course, issues to be considered. The fat injection augmentation takes much longer to perform than traditional breast augmentation. While implants can be placed in 60-90 minutes, fat injection augmentation can take 4-6 hours to perform. The fat placed in the chest may not “take” and some or all of it may be absorbed by the body. This means that fat injection augmentation may need to be repeated and it might not work at all in some patients. Due to the time it takes, fat injection augmentation may also cost much more than implant augmentation. The most important issue when dealing with fat injection augmentation is the topic of cancer monitoring and mammograms. The new techniques described in the recent publication discuss placing the fat in the muscle under the breast which should remove some of the concerns of mammography. In addition, experience with liposuction breast reduction has shown that manipulation of the breast does not usually result in calcifications and when it does. Those calcium deposits usually look benign and can be differentiated from malignancy. Laser Liposuction (Winter 2006) The news has been full of reports on laser liposuction techniques and it is important to understand what these techniques are and what they can, and can not, do. In the past, there has been a technique called laser-assisted liposuction which uses a laser applied to the skin to “melt” the fat after which a traditional suction cannula (straw) is used to suck out the melted fat. This technique is, in my opinion, total malarkey and is very similar to the N-Lite mentioned in the Winter 2005 media letter - it is a laser with no good use looking for a home. In these cases, the suction cannula is doing the work and the laser is there only to raise the fee charged by the surgeon. A newer laser liposuction, also known as SmartLipo®, has come on the market and has at least some value as a liposuction procedure. This procedure uses a laser that is actually put into the skin to lase, or melt, the fat. The liquefied fat is then removed with a small cannula just like in regular liposuction, or it can remain behind and get absorbed by the body. A possible additional benefit is that the laser might help the skin tighten up after the fat removal and avoid a cellulite type appearance that can occur after liposuction. There are several problems with the new laser liposuction procedure. The amount of fat that is removed is usually significantly less than what is taken out in standard suction liposuction, so only small areas with mild fat deposits are treated well. Also, traditional liposuction must be used in addition to the laser liposuction to get out the fat in larger cases. Finally, the laser tightening of the skin is totally unproven and may not actually take place. Once again, sometimes lasers are looking for a home and a purpose and it is important to see the results of early trials before trying a procedure for yourself. The Food and Drug administration approved silicone gel breast implants for use in all women over the age of 22. Silicone implants were the first modern implants ever used and were implanted in millions of women from 1962 until 1992. In the late 1980’s, however, questions arose as to the safety of silicone gel implants and they were taken off the general market in 1992. The media in combination with malpractice lawyers advanced the misconception that the implants could cause lupus, scleroderma, and other diseases. Time and true scientific study has shown that the implants do not cause these problems and are safe for use. Current silicone breast implants contain silicone that is much more cohesive than older models. Previous gel implants contained a gel that had the consistency of maple syrup while today’s implants contain a more Jell-O type material which will not run when cut open. Today’s silicone gel implants also have a more durable shell. That being said, it is important to note that all implants will rupture at some point and it is harder to replace silicone implants that their saline counterparts. Saline implants simply deflate and their shells can be removed and a new implant placed. Silicone gel will tend to stick to the surrounding breast tissues and will be tougher to totally remove requiring more of an operation. In the end, however, a replacement procedure should have an excellent result. The FDA also proposed MRI breast examinations every other year to look for ruptures in cases of silicone breast augmentation. This is because many silicone ruptures are “silent”. Since your body makes a scar around any implant placed in the body, that scar can hold the silicone gel in place even if the shell is broken. In the past, many doctors left silent ruptures alone. The FDA however, wants to find these ruptures if present. The problem of MRI monitoring of silicone breast implants is the cost. Insurance will probably not cover the cost and it could mean a $1000 to $2000 expense every other year. These MRI investigations are not mandatory, but they are advised and it is up to doctors and patients to discuss this, and all other issues, so that patients understand all the consequences of their choices. In the end, silicone breast implants offer another choice. They feel more natural than saline and are a great choice for patients with little breast tissue. The FDA does, however, advise MRI monitoring of these implants and when they do rupture, the operation to change them in more complicated. The incision to implant them is slightly longer and they can not be put in through a belly button or armpit approach. In the end, there are many issues to discuss and the only way to see what is best for you is with an in-person consultation.
Barbed Suture Face Lift (Summer 2006) A new technique for face lifting has been in the news. The technique, often called by the trademarked names Featherlift® and Threadlift®, use a special type of suture that has small barbs and prickles on it. The sutures are inserted to the skin under light anesthesia or local injection and they are then pulled to give a facelift type correction. The barbs are supposed to catch the skin so it can’t fall away from the lift and hold it in place. While the concept is interesting, I have found the results to be poor at best. Let me state from the outset that I do not do this procedure because the logic behind it is faulty and the results of published cases show little improvement in my opinion. When patients have extra skin, there is no magic that can make the situation better without getting rid of the extra skin and facelifts are still the gold standard of treatment. In those patients with early jowls, barbed suture lifts can improve the look temporarily by swelling the area and providing a short-term lift. Over a few months, however, the results are disappointing. If you are considering this surgery, I suggest you look carefully at the surgeon’s before/after photos. Take note if other procedures were also done that may be causing the improvement and look just how far after the surgery the photos were taken. Anyone can look better a month after surgery due to just swelling. The question is, “How well does it work a year after the procedure?
New Reconstructive Surgery/Bariatric Surgery Alliance (Spring 2006) Image Plastic Surgery has forged a strategic alliance with the Lighter for Life® Weight Loss Surgery Solutions program to help patients achieve their desired results following gastric bypass surgery. Paramus, NJ, February 8, 2006 - Image Plastic Surgery, based in Paramus, NJ, has forged a strategic alliance with the Lighter for Life® Weight Loss Surgery Solutions program to help meet the special, end-to-end needs of an increasing number of patients who wish to experience massive weight loss. Patients lose a large amount of fat after gastric bypass surgery. This extreme reduction in fatty tissue leaves patients with unsightly folds of skin and tissue that a plastic surgeon can correct. Post-bariatric body-contouring procedures include tummy tuck, brachioplasty, face-lifts, thigh lift, or body lifts. It is important for the plastic surgeon to use specialized surgical approaches and take specific safety measures for these patients. Through the strategic alliance between Image Plastic Surgery and Lighter for Life, both parties work to ensure that the patient understands the weight loss alternatives as well as the need for plastic surgery that comes after the excess weight is gone. They also help them to understand the inherent risks involved and what they can reasonably expect in terms of post-bariatric outcomes. The new strategic alliance will uniquely provide prospective patients with educational materials including linked websites that will answer questions about both bariatric and cosmetic surgery procedures. Laser Wrinkle Removal Without Down Time (Winter 2005) Over the past two months a new laser treatment has been in the news which claims to remove or improve facial wrinkles without superficial skin damage and the inherent downtime. The new therapy is often called the N-Lite® (Light Initiated Tissue Enhancement) and consists of a long-duration 585nm pulsed dye laser. The pulsed dye laser aims at blood and blood-containing areas. The new therapy claims to heat the middle and deep layers of skin while protecting the surface. By heating the deep layers, collagen fibers can be damaged and rearranged in a new and less wrinkled pattern. This is the same theory used in standard Erbium and Carbon Dioxide laser treatments, however, in these treatments the surface is obliterated during therapy and must heal for several weeks. The new treatment is based on research recently performed in Europe (Selective non-ablative wrinkle reduction by laser.1 According to this study, patients displayed improvement of wrinkles around the eyes after one treatment based on photographs of the area presented to a panel of judges. Additional biochemical data as also presented. It is important to weigh the possibility of cosmetic improvement against the financial cost and risks involved. In my opinion, the photos in the study displayed minimal improvement. However, the procedure does seem to be very safe and pain free. Whether or not the new laser truly achieves temperatures needed to rearrange collagen or can rearrange collagen in some other fashion is still matter of debate. Having worked with the pulsed dye laser for two years, I, personally, am not yet convinced that this new technology actually works, but I believe that continued research in the matter might soon show that the procedure could indeed be useful. 1 Bjerring P. et al. Journal of Cutaneous Laser Therapy; 2:9-15, 2000).
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