Grafting and Fat Transfer: What is the real story?

For many years, liposuction was associated with body contouring and fat removal, and was mainly in the domain of plastic surgeons.  Although the technique has been refined in some ways, fundamentally it still involves the removal of fat using small, often insignificant incisions, to reduce areas that have accumulated fat deposits.  We use the term “cannula” to describe the metal tube that is passed to extract the fat.  While the details of each surgeon’s technique may vary, most agree that nowadays it is appropriate to place fluid (“tumescent fluid”) into the area first, in order to best prepare the site for fat extraction and to minimize blood loss and discomfort.  The ideal patient who is a candidate for liposuction has traditionally been the patient who is close to ideal body weight and has focal areas of excess or prominent fat.  Often, these patients note that, however hard they may work to keep their weight at their best, certain areas “just don’t go away.”

Some of the ways that liposuction has evolved include the development of new kinds of cannulas, the use of different ways of aspirating the fat, and the use of different forms of energy to break up the fat for removal.  Energy forms that have been applied to fat tissues include lasers, ultrasound and radiofrequency.  The use of radiofrequency has even been used without any incisions or cannulas, and has been passed directly through the skin with no incisions.  In my opinion, the results achieved with that technique have been minimal or disappointing.  It is always worth considering the fact that, whenever the surgeon delivers any thermal energy to the tissues, the risk of scarring or burning the tissues is a real potential danger.

Over time, interest has grown in using fat for valuable purposes rather than discarding it as medical waste.  Although fat has been harvested and reinjected for many years, the process has hardly been standardized and the results have been extremely variable.  Some of the best “minds” in plastic surgery have had legitimate disagreements on whether transfer of fat really works, and even more disagreement on the best method(s) to use for fat transfer.  Evidence increasingly shows that fat can be transferred by injection techniques and survive, and that fat can also be used as a source of delivering other cells, such as stem cells, to different regions of the body.  I have personally experienced very gratifying results with fat transfer, provided certain principles were followed.  Here are some guidelines that I follow in my own practice:

1)   The technique of harvesting the fat is very important, and this includes the selection of the instruments used, the pressure used to extract it, and the manner in which it is separated from unnecessary fluid.  This concept would suggest that the use of newer laser-assisted or thermal systems of fat removal may be very unappealing because they can destroy these valuable cells.

2)    The technique of delivery of the fat is equally critical, as the fat must be able to thrive in its new location and receive adequate blood flow and nutrition.

3)    Patients who are thin may be very good candidates for specific types of fat grafting; they do not have to be overweight or carrying pockets of donor fat.

4)    Areas that are prone to constant movement, such as the lips, are less likely to retain the volume injected when compared to areas that do not move as frequently.

5)    If you assume that some percent of the fat will be lost over time, while the rest has a good chance of retention, you are embracing a more realistic approach and will likely be pleased with the results.

6)    Fat grafting can be a great addition to other surgeries that you may already be considering, such as face or neck lifting.

7)    Fat has the possibility to provide long-term volume enhancement; off-the-shelf fillers usually do not.  For large areas of fat grafting, such as the buttock area, fillers are not even a reasonable option given those that are FDA approved in the U.S.

Fat grafting and transfer is a growing area of interest, and you will likely see more advances on the horizon.  I will keep you posted . . .

To your health!

Saul R. Berger, MD, FACS

www.drberger.com

Popularity of Labiaplasty is Increasing

Over the past couple of years, I have seen more women seeking consultation for  labiaplasty than ever before.  Many people have speculated as to why there is increasing interest in these procedures, and explanations include social trends toward greater hair removal in the genital region thereby exposing the area more, as well as greater societal exposure to nudity.  Patients seek out treatment for a variety of reasons and come from all walks of life.  Some women feel self-conscious about the way they appear even if no one else sees the area.  Others develop irritation and physical symptoms related to pressure from excessive or protrusive tissues.  Specific reasons that women seek consultation include:

1) The desire to reduce the size or improve the shape of the labia minora or labia majora for cosmetic purposes.  Many view the excessive and protrusive tissues as appearing "stretched" or excessive, and not youthful.  As with other aesthetic procedures, correction can improve self-confidence.
2) The desire to reduce the labia minora size because of irritation, pressure, or pinching during sports, exercise or certain activities.  There are also circumstances in which such individuals are uncomfortable during sexual relations secondary to traction and irritation.
3) Many women have an imbalance in size or an irregular shape that gives the appearance of an "abnomality" and can cause patients to feel self-conscious.

Although labiaplasty is offered by a variety of medical professionals, I believe that the well-trained plastic surgeon is ideally suited to handle this kind of operation with skill and finesse.  While historically, many surgeons simply "cut off" the extra tissue and "sew it up," such procedures can leave a lengthier scar at the edge of the labia and could result in increased sensitivity in that area.  My own philosophy, on the other hand, is to bring the principles of plastic surgery to this arena and use smaller scars and avoid placing them along the labial edge when feasible.  These techniques have proved very worthwhile.

I feel very privileged to be able to offer two options to patients at my center in Encino/Los Angeles, California.  One option is the full labiaplasty procedure performed without the need for general anesthesia.  Patients remain completely comfortable and pain-free while the correction is performed, but are able to be discharged in a short time, alert and awake, and without having the after-effects of anesthesia or the need to have bloodwork checked in advance.  The total cost for this option is also lower, with fees that are some of the most affordable in plastic surgery.  The other option is the use of general anesthesia, which provides the ultimate in ease for the patient experience.  Patients who undergo labiaplasty under general anesthesia tell me that the procedure seemed to have taken "only a few minutes."

Many patients begin their journey toward this procedure by reading reviews such as this one and gaining awareness of what is involved.  The next step for interested patients is the scheduling of a consultation to assess each patient's specific needs.  At the first visit, I typically give my patients the information they need to understand the procedure and the risks, discuss the option of having it done with or without general anesthesia, and provide a copy of the aftercare instructions so that each individual is well-prepared in advance.  The recovery is not very difficult, and often requires only a few days off work if one's job is office-based.

For greater detail and real case analyses, you can find more detail at my web site: www.drberger.com.

How About a Drive-Thru Facelift?

We are frequently exposed to ads for surgery purported to rejuvenate the face in seemingly remarkable ways. "In as little as one hour . . . with miraculous results . . . with no scars or down time . . . over your lunch break . . . " and so on. Usually there are accompanying photos which show dramatic results that appear almost "too good to be true." Is it all true?

It is important for individuals seeking facial rejuvenation to have both a careful evaluation by a professional who performs reliable procedures and an understanding of the various options available. A successful treatment plan usually considers the recovery and down time involved, the possible risks of the treatment as well as the patient's medical status, and the pros and cons of the choices (and there are many choices nowadays). Did you know that some of these heavily advertised procedures are offered by "franchised" operations that involve non-physicians for patient screening and evaluation? Did you know that some of the procedures that are speedier than others may be a poor match for certain patients and can increase the risk of side effects or the amount of down time? Did you know that some of the photos which appear in ads represent results achieved only weeks after surgery (and may not hold up over time)? Did you ever think that an effective procedure performed over lunch would allow the average individual to return to work "business as usual?"

For most of us, applying common sense would raise suspicions and doubts about many of these claims. The aging process in the face is quite complex, and involves many factors including loss of skin tone, changes in fat volume and location, and changes in the skeleton itself. Each of us ages in our own way based upon factors such as genetics, environmental influences, diet, and lifestyle (and there are other factors). Surely, common sense would suggest that we are not all candidates for the identical treatment!

More than twenty years of plastic surgery practice have allowed me to make some observations:

(1) Good results are generally based on a skilled assessment of the aging changes for a specific individual, rather than a "cookie cutter" approach;

(2) Often, the best results require a larger procedure that may involve longer healing and recovery instead of a "quickie" approach;

(3) A non-physician or non-expert evaluating a patient in order to devise a treatment plan that is implemented by a physician creates a "disconnect" or fragmentation of care that may compromise the results; and

(4) While some "quickie" procedures are completed in a short time, they may create unnatural results.

As with many things in life, if it looks "too good to be true," it often is. Quick and easy works great for online shopping . . . just don't shop that way when it comes to your looks!

To your health!

Dr. Berger

Some Thoughts About Breast Reconstruction After Cancer

With the incidence of breast cancer at nearly one in eight females, I see patients with this diagnosis almost every day in Encino and the Los Angeles, California areas.  The patients that I treat are in various phases of care, ranging from newly diagnosed to survivors beyond five years.  Nowadays, many are receiving chemotherapy and radiation, and many are undergoing mastectomy rather than breast-conserving lumpectomy.  As one member of a team of specialists, the plastic surgeon tries to focus on the restorative aspect of breast cancer care.

Patients with new cancer diagnoses are faced with an early decision of lumpectomy and radiation versus mastectomy.  While conserving the breast is an appealing idea, it does not work well for many women, and can result in a deformed breast that is difficult to improve.  I have also seen a number of cases that developed cancer in the remaining breast tissue left behind after lumpectomy in spite of radiation treatment.  Nevertheless, I tend to advise the option of breast preservation if it is likely to give a good cosmetic result.  If not, the mastectomy, which removes almost all of the breast tissue from the cancer site, may be the better option.

Patients who are potential candidates for mastectomy should, ideally, see the plastic surgeon early on in the workup process to ascertain the role of plastic surgery for them.  There is no substitute for a detailed and thorough examination, assessing each patient for options involving both implant approaches as well as body tissue reconstructions.  I have heard so many women say, “I wish I knew that before . . .,” as they had never seen a plastic surgeon until they were already healing from the mastectomy.  As a general rule, use of implants and expanders are shorter procedures involving less hospitalization.  Implants are limited in how they can be placed and used to shape a breast, do not fare well in areas that have had or will have radiation, and can be difficult to match to an opposite “natural” breast.  Because of these limitations, they often work better in cases of double mastectomies.

Tissue reconstructions can require longer operative and hospitalization times, but offer advantages in shaping and in radiated areas.  Their success relies on adequate blood flow into the tissues,  a factor that the plastic surgeon is attentive to throughout the surgery and post-operative period.  The two most common sources of body tissue are the tummy and the back areas.  Not everyone is a good candidate for this approach; your plastic surgeon can guide you.

Some words of advice if you are facing breast cancer or know someone who is . . .

      1)    Take a deep breath, and try to stay focused to make the best choices you can.  Experienced plastic surgeons know that you are sometimes under short time constraints to make decisions about your care, and they will try to give you as much information as possible.  Meet with them as early as possible.

      2)    With the current state of chemotherapy and additional treatments, survival with this diagnosis has made great progress in the last few decades.

      3)    The changes in your body tissue that result from a course of radiation may never go away.  They may have a major impact on your reconstruction in the future.

      4)    If a lumpectomy will likely deform your breast in a way that could disappoint you, think carefully about whether the mastectomy option would be a better choice.

      5)    All other factors being equal, the body tissue reconstruction frequently offers the best long-term result.

      6)    If you need reconstruction after mastectomy, good integration of your plastic surgeon with the other members of the team is a strong advantage.

                                             To your health,

                                             Saul R. Berger, MD, FACS

                                           www.DrBerger.com

Some Thoughts About Medical "Tourism"

A couple consulted with me some time ago about a number of cosmetic issues.  Both had traveled to a Central American country for cosmetic surgery.  Both individuals had multiple procedures to the face and body, including facelift, brow lift, breast surgery, tummy tuck and more.  Frankly, it was difficult for them to know where to begin describing the problems that resulted, including sutures that still needed to be removed more than one year after surgery, scars that left them looking “strange,” and residual cosmetic issues that were never corrected.  In actuality, they began the consultation acknowledging that they had made a “big mistake” in traveling for surgery, but were trying to maintain a positive attitude in moving forward.  What was their prime motivation for surgery in another country?  Cost.  They spent about 50% of the cost of similar surgery in the U.S.  Some of their problems were correctable, and some were not.  Ultimately, they never underwent additional surgery -- they were not able to budget for the corrective work.  How did they find and “screen” the cosmetic surgeon who treated them?  The internet.

The desire to look one’s best and the benefits of improved appearance on both a personal and professional level have been recognized for many years.  Interestingly, there are many studies in the field of sociology that have documented measurable advantages, on a societal level, to possessing beauty and attractiveness.  Studies have even documented this fact across cultures and geographical boundaries.  The wild popularity of such relatively “simple” procedures such as Botox Cosmetic and the billions of dollars spent on skin care attest to our desire to “look our best” as much as possible.  Despite the current state of the domestic and world economies, individuals are still seeking aesthetic treatments and surgeries.  In order to reduce costs, some people have traveled to other destinations for their treatments.  Is it worthwhile to travel abroad for cosmetic surgery, and what are the risks?  What is involved in “surgical tourism?”
 

Some years ago, medical tourism described upper social class individuals traveling to countries for specialized skin care, spa therapies, mineral baths, or other unique treatments in pampering settings such as cities in the Mediterranean.  In more recent times, it has become commonplace for foreigners to travel to the U.S. for treatments that were either unavailable or associated with major delays in their native country.  The escalation in health care costs in the U.S. along with advances in aviation travel have increased the volume of Americans seeking medical care outside the U.S. for everything from organ transplants to cardiac surgery.  Specifically in the area of cosmetic surgery, people have traveled for procedures such as liposuction, facial cosmetic surgery, tummy tucks and much more.  In almost all cases, the motivation for travel is a lower price.  The obvious question is: are those savings justified?

While there is no definitive answer to this question, and there are certainly skilled and competent surgeons practicing around the world, what risks do patients face when traveling abroad for surgery?  The risks fall into several general categories:

1. Competency risk – does the physician have the necessary training to perform the procedure(s) safely and to achieve desirable results?  It can be very difficult for Americans to ascertain the quality of training and certification outside of the U.S.  Satisfactory results in a friend or family member may not translate to your results.
2. Facility risk – does the facility follow the safest protocols to ensure sterilization of instruments and proper function of equipment?  Are there contingency plans for emergencies?  Do they have the latest equipment should something untoward occur?  As medical director for an ambulatory surgery center in Encino, California, I can tell you that we use many safety systems about which most patients are unaware.  Did you know that we confirm the reliability of every sterilization cycle by using a separate biological test?  Did you know that we maintain a completely autonomous power backup system that automatically activates in the case of regional power loss so that surgery is not interrupted?  Did you know that an independent technician performs regular site visits and checks every piece of electronic and anesthesia equipment for proper function and maintenance?  These are just a few examples of many.
3. Follow-up risk – how does a patient propose to get the follow up care and information that they may require?  Most surgeries require a full healing period of at least 12 months.  Once returning to the U.S., patients no longer have the chance for direct “hands on” evaluation of their surgery by the practitioner.  What if they experience a problem or require some minor adjustment, such as a scar revision?
4. Complication risk – how do patients handle complications, such as infections or keloid scars?  What if their medical insurance does not cover the complications of such elective cosmetic procedures?  Are complication risks higher because of travel itself?  For example, prolonged airplane travel could increase the risk of a clot in a leg vein, with the risk of a life-threatening clot moving to the lungs.

So, is it worthwhile to travel for surgery?  Of course, price has to be figured into any assessment for cosmetic surgery.  But I advise my patients to make sure that cost is not their prime motivating factor.  Remember, surgical tourism can result in medical problems, and any savings could be easily wiped out.  Caveat emptor!

To your health,

Saul R. Berger, MD, FACS