Ruben Abrams MD FACS | Aesthetic | Cosmetic Plastic Surgery | (310) 651-8881

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WHAT IS “BODY DYSMORPHIC DISORDER”?

WHAT IS "BODY DYSMORPHIC DISORDER"? image

WHAT IS “BODY DYSMORPHIC DISORDER”?

Body Dysmorphic Disorder is a term that was coined to describe a certain psychological condition that involves obsession with one’s appearance and consisting of certain symptoms which have been somewhat clearly categorized during the past few decades. “Dys” means “incorrect, wrong” and “morphic” means “shape, related to shape”.  So “Dysmorphic” means “Incorrectly shaped”

From time immemorial people, especially women, have been interested in a more presentable and more aesthetically pleasing appearance.  During the ages before photography people would obviously choose certain good-looking individuals as their model and try to copy them in terms of make-up, hair style, clothing etc.  With the invention of photography and print media people now had ready access to photos of handsome men and beautiful women and compared their appearance to those individuals.  Then came the era of cinema and TV, and certainly Hollywood brought to light generation after generation of extremely handsome men and beautiful women, which obviously completely changed people’s perception of beauty.

This has lead to “appearance” and “one’s looks” gaining a most prominent role in people’s lives.

Psychology And Dysmorphic Disorder

BREATHING DIFFICULTY AFTER COSMETIC NASAL SURGERY imageHowever, there are certain individuals who psychologically are susceptible to having “low self-esteem”, and constantly trying to find flaws with their appearance.  This is beyond a simple trying to imitate role models in fashion magazines and movies.  Such individuals have a totally distorted perception of themselves.  They are constantly conscious of what they perceive in their appearance as being abnormal and are under constant impression that they are being watched by everyone for this incorrectly perceived flaw.  They are eitherconstantly in front of the mirror, or avoid looking themselves in the mirror totally.  They often have several cosmetic procedures done, but are always unhappy no matter how good the outcome.  They need constant re-assurance by others about their appearance.  And there are many other symptoms.

The Impact Of Media On Body Dysmorphic Disorder

The media has played a major role in the prevalence of this problem.  First of all, the media has been responsible for literally brain-washing the public into this notion that life is all about “appearance”.  Secondly, and more importantly, the media has engraved such a distorted perception of beauty in the minds of the public by falsifying images and placing Photo-Shopped bodies in front of people’s eyes that literally do not exist in reality, that this has created a chaotic situation resulting in an ever-increasing number of individuals with Body Dysmorphic Disorder.  The image below, courtesy of Google Images, is a good example of how a person with this disorder views herself in the mirror.WHAT IS "BODY DYSMORPHIC DISORDER"? image

This is why one of the main duties of a plastic surgeon is to be aware of this disorder and to diagnose it promptly.  Because people with this disorder often refer for different plastic surgery procedures which never make them happy.  Sometimes it is necessary to seek help from psychologists to deal with such individuals.

WHY ARE SOME PEOPLE AFRAID OF GENERAL ANESTHESIA?

WHY ARE SOME PEOPLE AFRAID OF GENERAL ANESTHESIA image

WHY ARE SOME PEOPLE AFRAID OF GENERAL ANESTHESIA?

Over the years we have had many patients who have expressed concern regarding general anesthesia.  Some have had previous bad experiences such as nausea and vomiting, others have never had anesthesia but have heard of people with such side effects, yet others have had anesthesia and felt that they were lethargic or had memory lapses for a while, and finally some have heard some horror stories about “people not waking up from general anesthesia”.

So, lets look at this with some detail:

General Anesthesia Gases

Yes, the most common side effect of general anesthesia is nausea and vomiting.  Many years ago, this was the accepted norm.  Meaning that every patient who underwent general anesthesia was expected to have some degree of nausea and vomiting during the first 24 hours after surgery.  This side effect is mainly related to the anesthetic gas that is used.  General anesthesia is usually started with injection of a deep narcotic such as Propofol and maintained with inhalation of an anesthetic gas.

Since around 20 years ago the anesthesia community started looking into this.  More modern anesthetic gases with less chance of nausea and vomiting were developed and this research into development of newer anesthetic gases continues.  As it stands the currently available and popular gases hGENERAL ANESTHESIA AND SURGERY RISKS imageave much less risk of nausea and vomiting.  The most commonly used of these gases is Ceboflorane.

General Anesthesia Techniques

Another major change that occurred was modification of technique.  The anesthesiologists realized that certain techniques had higher risk of nausea and vomiting than others.  The more modern techniques that were developed have been adopted by most currently practicing anesthesiologists.

Most important among these techniques was the use of certain anti-emetic (prevention of nausea and vomiting) medications before induction of anesthesia, during surgery if surgery was prolonged, and just before the patient waking up.  A whole range of medications have been developed for this purpose.  But the one that is most commonly used today is “Zofran”.  In addition most anesthesiologists inject a small dose of a steroid such as Decadron before induction of anesthesia and this is also known to reduce the chance of nausea and vomiting.

Complications Of Anesthesia

Lethargy for a few days after anesthesia is sometimes seen.  This has to do mostly with the patient’s genetics, physical condition, and personal history.  However it is not something that can be predicted or prevented and it never lasts more than a few days.

Memory Lapse is probably less common than lethargy.  Again, it is unpredictable, and unpreventable.  Fortunately, just like lethargy, it does not last for more than a few days.

Prolonged Recovery From Anesthesia is occasionally seen.  We see some patients who take longer to totally wake up from anesthesia.  In most cases this is related to certain anesthetic substances and if the patient has a history of this problem his / her previous anesthesia records would need to be reviewed to make certain that those substances responsible for this problem are not used.  However, in very rare instances patients genetically lack a certain enzyme (acetyl choline esterase) necessary to metabolize a substance that is used to paralyze the muscles during anesthesia.  As a result even with being awake the patient will not be able to breathe on their own.  This is usually a genetic condition that patients are aware of and need to notify the anesthesiologist beforehand.

Malignant Hyperthermia and Anesthetic Death are the two most dreadful, extremely rare complications of anesthesia which will be discussed separately in future blogs.

ROUND BREAST IMPLANTS VS SHAPED ANATOMICAL IMPLANTS

ROUND BREAST IMPLANTS vs SHAPED ANATOMICAL IMPLANTS image

ROUND BREAST IMPLANTS VS SHAPED ANATOMICAL IMPLANTS

Many of our patients who refer for a Breast Enlargement consultation have heard or read about SHAPED ANATOMICAL IMPLANTS (ANATOMICAL FORM-STABLE IMPLANTS), formerly known as tear-drop implants and have questions as to whether they have any advantage over ROUND BREAST IMPLANTS.  In most cases the question is resolved when patients view sample photos of patients who have received standard Round Breast Implants.

Round Breast Implants Or Shaped Anatomical Implants? Which One Is Better?

Silicone Breast Implants SafetyThere is much controversy in this regard, but in our opinion, there is no advantage with Shaped Anatomical Implants over Round Breast Implants.  The shaped anatomical Implants are much more expensive and are more difficult to insert and properly position because they are textured surface implants, requiring larger incisions and only using the inframammary fold approach.  The standard round implant is available in smooth surface (our preference) and textured surface.  The smooth surface implants can be inserted through any of the available approaches, with the peri-areolar approach being our preferred one since it leaves the most inconspicuous scar.

However, there was a recent article in the Aesthetic Surgery Journal which is the official organ of the American Society for Aesthetic Plastic Surgery, in which assessors with no knowledge of the type of breast implant were asked to evaluate breasts with either Round Breast Implants or Shaped Anatomical Implants. They were asked to determine what type of implant had been used and to assess variables such as upper pole contour, natural shape and feel, etc.  Even though in this study the scores were slightly higher for the Shaped Anatomical Implants  but the difference was not statistically significant.  Meaning that for all practical purposes there is no difference between the two types of implants.

Reference:

Aesthetic Surgery Journal 2015, Vol 35 (3) 273-278.

BREAST REDUCTION AND THE RISK OF NIPPLE SENSORY LOSS

BREAST REDUCTION AND THE RISK OF NIPPLE SENSORY LOSS image

BREAST REDUCTION AND THE RISK OF NIPPLE SENSORY LOSS

Many of our clients who refer for a breast reduction consultation come in with preconceived notions regarding the nipple/areola complex and the risk of nipple sensory loss.  A lot of these ladies are under the impression that in every case of breast reduction the patient looses feeling to the nipple/areola complex and many women have refrained from surgery for excessively heavy breasts out of this fear because feeling to the nipple is very important for them.  Still others think that feeling to the nipple is lost in “most cases”. 

So, in order to clear some of this confusion lets discuss this topic in some detail.

WHAT NERVE IS RESPONSIBLE FOR NIPPLE SENSATION?

HOW MUCH CAN BREASTS BE REDUCED WITH BREAST REDUCTION SURGERY? imageFeeling to the nipple/areola complex is provided by the 4th intercostal nerve (the sensory nerve that travels between the 4th and 5th rib, starting from the spinal cord and coming all the way to the front).  This nerve, once it reaches the lateral border of the breast, penetrates the muscular layer over which the breast sits, and travels through the breast tissue towards the nipple/areola complex.  It is deeply seated within the breast tissue until it gets close to the nipple/areola complex, then it penetrates the breast tissue and becomes superficial, spreading within the substance of the nipple/areola complex.

So, in order to maintain sensation to the nipple/areola complex this nerve has to be preserved.  For this reason, most breast reduction techniques are based on maintaining a wide “neuro-vascular pedicle” for the nipple/areola complex, in order to preserve the vascular supply and sensation.

However, there are different techniques of breast reduction and each has its own rate of complications, including nipple sensory loss.  The most commonly used technique is the inferior pedicle Wise pattern technique.  In this technique of breast reduction, the chance of nipple sensory loss in most studies is around 5%. 

In our own series of around 1,000 breast reductions, the majority of which were done using the inferior pedicle, we have had only 2-3 nipple sensory losses, meaning a risk of only 0.3%.

Other techniques of breast reduction have a higher risk of nipple sensory loss.  For example in the superior pedicle technique the chance is around 50%, and in the Free Nipple Graft technique, the chance is 100%.  These are technique that in our practice we almost never use.

BREAST IMPLANTS AND THE RISK OF NIPPLE SENSORY LOSS

BREAST IMPLANTS AND THE RISK OF NIPPLE SENSORY LOSS image

BREAST IMPLANTS AND THE RISK OF NIPPLE SENSORY LOSS

Many of our clients who refer for consultation on breast enlargement using implants come in with incorrect preconceived impressions regarding this operation.  For example many times we hear: “I don’t want my nipples to be touched because I don’t want to lose feeling to my nipples”, or “Isn’t the operation always done through the belly button?”  So in order to clear some of the confusion, here is a brief discussion on the different approaches.

Different Approaches of Breast Implants

Inframammary: “Infra” means “under” and “mammary” of course means “breasts”.  This word refers to the inframammary fold.  This is the fold under the breast.  Through a small, usually 2 inch incision, the pocket for the implant can be opened and the implant can be inserted.  This is the original technique and is probably the most commonly used till this day.  It is an excellent approach and the resulting scar is usually quite inconspicuous.  However, certain women may develop visible scars which may show when they wear a tank top or bikini.

SALINE IMPLANTS OR SILICONE GEL IMPLANTS FOR BREAST AUGMENTATION? imagePeri-areolar: “Peri” means around, and “areolar” refers to the areola.  This is what most people incorrectly refer to as “through the nipple”.  The incision in this approach is placed around the lower half of the areola.  It is a more difficult approach compared to the inframammary approach.  In our practice, however, it is the preferred approach.  The reason is that it almost always heals with invisible scars.  And even if the patient ends up with visible scars they are always hidden and only the patient and her partner know about them.  Of course there are cases where this approach is not practical due to the small size of the areola.

It needs to be clarified here that NIPPLE SENSORY LOSS has nothing to do with what approach is used because it happens when the outer part of the pocket is dissected using sharpinstruments that can injure the nerve that brings feeling to the nipple.  Therefore it can happen with any approach.  Most statistics show anywhere from 2% to 5% incidence.  In our practice we have not even seen one case of nipple sensory loss over the past 25 years with breast implants because all dissection is done bluntly.

Transaxillary: “Trans” means “through”, “axillary” means “arm pit”.  It is done through an approximately 2 inch incision that is placed in one of the axillary creases.  It is a satisfactory approach, especially for placement of implants behind the pectoralis major muscle.  There are two issues.  Although the scar usually is inconspicuous, it can still be a visible and conspicuous scar and if that happens then every time a woman raises her arm while wearing sleeveless shirts the scar will show.  Another issue is that since the incision is some distance from the pockets there is a higher chance of asymmetrical dissection and placement of implants, resulting in what patients refer to as “lopsided”.

Trans-Umbilical: This approach is the least used approach, almost abandoned.  As the name implies, if refers to placement of breast implants through the umbilicus.  The procedure is known as TUBA (TransUmbilical Breast Augmentation).  When first developed it created a lot of excitement, claiming to place breast implants with no scars on the breast!  However, since the technology is quite complex and everything is done blindly it resulted in many problems of asymmetry, misplacement, etc.  Therefore, it gradually lost its popularity.  Furthermore, the implants that were developed for this procedure are saline implants since silicone implants cannot be inserted through the tiny path that is created in this procedure.  With the comeback and increasing popularity of silicone gel implants the TUBA is on its way out.

WHAT IS PRP AND WHAT IS IT USED FOR?

WHAT IS PRP AND WHAT IS IT USED FOR image

WHAT IS PRP AND WHAT IS IT USED FOR?

PRP stands for Platelet Rich PlasmaPRP Treatment has become popular in different fields of medicine, including cosmetic surgery, and we have many clients who ask about it.  So lets see what PRP really is and how it can help us.

Different Components of PRP

First lets understand what the different components of PRP are.  As most people may know, blood consists of red blood cells, white blood cells, and platelets.  These are immersed in a liquid medium called plasma.  Platelets are primarily responsible for initiating the blood clotting mechanism, by aggregating together in cases where there is a disruption in the continuity of blood vessels and basically stopping the bleeding until a more secure blood clot forms.

In the 1970’s some researchers were able to identify certain growth factors that exist in platelets and it was SCARRING AFTER PLASTIC SURGERY, CAN IT BE CONTROLLED? imagerealized that platelets have a much more significant role in the human body than just initiating the clotting mechanism.  This led to the idea of harvesting these platelets by a certain centrifuge process and using the resulting emulsion to facilitate healing in certain types of injuries and ailments.  The emulsion would consist of only plasma and platelets, without the other blood cells.

The regular concentration of platelets in blood is around 200,000 per microliter (cubic millimeter).  With the platelet harvesting process the concentration of platelets in the plasma was increased by five-fold, hence the resulting emulsion came to be known as PLATELET RICH PLASMA.

Platelet Rich Plasma Treatment

To this day PRP has been used to enhance healing in many types of injuries, including sports injuries, osteo-arthritic problems, nerve injuries, etc.  It has gained much popularity with the media’s help in reporting popular athletes receiving PRP treatment.

There have been many trials of using Platelet Rich Plasma in cosmetic surgery, for facial rejuvenation, enhancing hair growth, etc.  But so far most reports regarding this are based on individual experiences and there is no prospective double-blind study to show the scientific and statistical efficacy of PRP treatment, especially in cosmetic surgery.

Here are some links you may be interested in:

http://www.medscape.com/viewarticle/759592

http://www.informationvine.com/index?am=broad&q=prp+plasma+therapy&an=google_s&askid=562657a1-1bde-4a23-a9e4-d61879422cf9-0-iv_gsb&kv=default&gc=0&dqi=&qsrc=999&ad=semD&o=33787&l=&af= 

WHAT IS “LARGE VOLUME” LIPOSUCTION? DOES IT REALLY WORK?

WHAT IS "LARGE VOLUME" LIPOSUCTION? DOES IT REALLY WORK? image

WHAT IS “LARGE VOLUME” LIPOSUCTION? DOES IT REALLY WORK?

In the early days of liposuction, before the development of the TUMESCENT TECHNIQUE it was noted that the fat that was aspirated contained approximately 30% of blood. Meaning that with each 1000 cc of liposuction the patient lost around 300 cc of blood. Therefore, after some preliminary research the safe limit of liposuction was placed at 2,000 cc which would translate to 600 cc of blood loss, equivalent to one unit of blood. This was considered safe because everyone safely donates one unit of blood with no noticeable consequences on the body.

With the advent of the tumescent technique the amount of blood lost during this procedure dropped from this 30% to only around 5%. Hence it was determined that much larger volumes of fat can be removed with liposuction with no significant ill effects on the body.

STORY BEHIND LIPOSUCTIONDoes Liposuction Mean loosing weight?

However, some unqualified individuals deceived many people into thinking that the process is actually a means of loosing weight. Not realizing that it is not just the blood loss that matters, but with larger volumes of liposuction there are water and electrolyte changes that take place within the body that need to be carefully monitored and corrected.

In our experience, it is not a means of weight management, but rather a contouring technique that is best effective in individuals who are close to their ideal weight. Effective procedure usually hovers around 2,000 – 5,000 cc of pure fat, meaning fat that remains after the fluids have settled. Individuals who can spare large volumes of fat, in the 10,000 cc and above range, are in most cases not suitable candidates for it and they have an obesity issue which will not be corrected with liposuction. As a matter of fact, in most cases the aspirated fat will come right back in no time.

When used appropriately, in the right candidate, and in the hands of qualified surgeons, this procedure is a very effective technique with extremely rewarding results, and absolutely the safest cosmetic surgery procedure.

CAN YOU MELT AWAY FAT BY INJECTING A SUBSTANCE INTO THE FAT POCKET?

CAN YOU MELT AWAY FAT BY INJECTING A SUBSTANCE INTO THE FAT POCKET? image

CAN YOU MELT AWAY FAT BY INJECTING A SUBSTANCE INTO THE FAT POCKET?

Even though for most people it has become clear that there is no substance that can be injected into fat pockets in order to melt away the fat, we still have clients who refer stating that they know of certain friends who had this done and their fat went away!

Unfortunately many people only hear what they want to hear and disregard facts that are provided by credible sources.

FDA Warnings on Lipodossolve Injections

This all started about 10 years ago when some shadowy individuals claimed that they are able to melt away fat in unwanted areas by giving the individual a series of injections in the area.  This was quickly taken up by a lot of other shadowy providers and health spas and resulted in a lot of deceptive and misleading advertising.  To the extent that the FDA sent out warning letters to the respective health spas, instructing them to put a stop to their deceptive ad campaign and some who did not comply were deprived of their license to continuFAT GRAFTING TO BREASTS, COSMETIC / RECONSTRUCTIVE, DOES IT WORK Imagee functioning.  Here is an excerpt of FDA’s report on this:

“On April 7, 2010, the U.S. Food and Drug Administration issued warning letters to six U.S. medical spas(cosmetic medical businesses that operate under the supervision of a licensed health care professional) that they are making false and misleading claims about their lipodissolve products. Lipodissolve, also known as lipozap, lipotherapy, mesotherapy, or injection lipolysis, is a cosmetic procedure that involves a series of injections over a period of months with the intention of dissolving pockets of fat in the body.

The false and misleading claims about these lipodissolve products include statements that they eliminate unwanted fat, have an outstanding safety record, and are superior to other fat loss procedures. Some medical spas also claim that lipodissolve products can treat medical conditions, such as male breast enlargement, benign fatty growths, and surgical deformities. FDA is not aware of any credible scientific evidence to support any of these medical uses.

In addition to the actions, the FDA also issued a letter to the Brazilian firm Zipmed Mesoone for selling unapproved lipodissolve products directly to consumers over the internet, and an import alert was also issued to prevent the distribution and importation of lipodissolve drug products into the United States.”

For a full copy of the FDA report you can also visit:

http://www.fda.gov/drugs/guidancecomplianceregulatoryinformation/pharmacycompounding/ucm207624.htm

HOW MUCH CAN BREASTS BE REDUCED WITH BREAST REDUCTION SURGERY?

HOW MUCH CAN BREASTS BE REDUCED WITH BREAST REDUCTION SURGERY? image

HOW MUCH CAN BREASTS BE REDUCED WITH BREAST REDUCTION SURGERY?

Many women with excessively large breasts refer to us stating that they have procrastinated for years about having a breast reduction because “I’m afraid of the surgery”, “I have heard you lose feeling to the nipple”, “I don’t want my nipples to be removed”, etc.  Most of these fears are based on misinformation and preconceived notions.  But many are either afraid that their breasts will become “too small” or “remain too large”.

Breast Size

One thing that I have mentioned many times, and I need to repeat here is that cup sizes are arbitrary and do not really reflect the breast size. Cup sizes vary from one manufacturer to another.  For example what is considered a C cup at Macy‘s is a D cup at Victoria’s Secret.  This is called psychological upsizing, meaning making their customers feel good by calling their breast size a D cup while it is really a C cup by most standards.

What criteria do insurance companies use to cover breast reduction? imageSo, the size and shape of breasts after a breast reduction depends on many factors which an experienced plastic surgeon has to be mindful of.  These factors start with the patient’s height and weight.  Obviously putting B cup breasts on a lady who is 180 lbs and 6′ tall would be ridiculous.  So the final size has to be proportional to the
body.  Then comes the characteristics of the breasts, size, contour, density, etc.  For example, if a lady is an H cup and wants to be a B cup, it would probably not be possible, unless certain rare techniques are used.  Even then, usually breasts of that size are excessively wide at the base, and this will not allow reduction to a B cup.

Important Discussion Before Operation

It is very important for the patient and plastic surgeon to discuss this operation in detail, for the patient to fully understand the process, the scars, and what to expect, and for the surgeon to fully understand what the patient has in mind and whether it is realistic or not.  This is one of the most technically demanding procedures in plastic surgery and truly requires experience in order to deliver properly.  However, the most common comment we have heard from patients after this operation is “I wish I had gone smaller”.  The reason is that patients have usually gotten so used to excessively large breasts that they cannot envision themselves with small breasts and they are worried that they will end up too small.  Of course in most cases ladies ask to be made as small as possible, some even want to be “flat chest”.  But there are those who keep requesting that the doctor not make them too small, and then after surgery they wish they had asked to be made smaller.

For these reasons, the plastic surgeon not only has to be technically skilled and experienced, he / she also has to be a good psychologist and to understand what exactly is going on in the patient’s mind. 

WHAT IS TISSUE GLUE OR FIBRIN GLUE?

WHAT IS TISSUE GLUE OR FIBRIN GLUE? image

WHAT IS TISSUE GLUE OR FIBRIN GLUE?

Some people may have heard the term “TISSUE GLUE” because some patients ask about it.  So here is a brief description of what it is and what it is used for.

Tissue Glue

Most plastic surgery procedures involve removing excess tissue, usually loose skin and fat.  This requires bringing the remaining tissues together and repairing them under no tension.  For this purpose we have to do a lot of soft tissue dissection and mobilization.  This means separating different layers of tissues from each other in order to move tissue around, and close the remaining gap under no tension.

Dead Space

SCARRING AFTER PLASTIC SURGERY, CAN IT BE CONTROLLED? imageThis separation of tissue layers creates what we call “dead space” and it can take anywhere from a few hours to a few days for the tissues to “adhere” together and eliminate this dead space.  During this time the body has an inherent tendency to secret fluid into this dead space, either in the form of blood (hematoma), serum (seroma), or a mixture of both (sero-hematoma), because the tissue surfaces are “raw”, meaning that they have been freshly separated from each other.

How Does Tissue Glue Work?

Traditionally it has been customary to place “suction drains” in between the tissues that have been separated, which many people are familiar with.  These drains evacuate the fluid and create negative pressure in order to help the tissues adhere together faster.  But there have been studies that have shown that the use of suction drains does not actually eliminate the chance of fluid accumulation.

Since the early 1990’s different forms of tissue glue have become available to plastic surgeons through extensive research in order to cause an immediate adherence of tissues to each other and eliminate the need for suction drains.  Some of these products are synthetic and act in the same manner that SuperGlue does.  Dermabond is one form of synthetic tissue glue that is often used in place of sutures for small lacerations.  But the more efficient form of tissue glue that can be used inside tissues is one that is custom made for each individual by using the FIBRIN from the individual’s own blood.  Fibrin is the proteinous substance that the body creates in order to adhere tissues together.  Through a complex process using the patient’s own blood FIBRIN GLUE or TISSUE GLUE can be produced. 

There are studies that have shown that by using tissue glue the chance of fluid accumulation (seroma, hematoma) can be reduced or even eliminated.  Of course this is not something that all experienced plastic surgeons are in agreement about, because the superiority over the use of suction drains has not been definitively established and it involves additional expenses on the part of the patient since the tissue glue production is a fairly expensive process.