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.

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

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.

BREATHING DIFFICULTY AFTER COSMETIC NASAL SURGERY

BREATHING DIFFICULTY AFTER COSMETIC NASAL SURGERY image

BREATHING DIFFICULTY AFTER COSMETIC NASAL SURGERY

We frequently see patients in our practice who have undergone a rhinoplasty (cosmetic nasal surgery) and have ended up unable to breathe through the nasal airways.  What could be the cause?

What Is causing breathing difficulty?

In most cases cosmetic nasal improvement results in narrowing of the nasal airways.  The majority of patients who end up unable to breathe through the nasal airways after cosmetic rhinoplasty are patients who had a borderline narrow airway to begin with and this was not paid adequate attention to by the surgeon.  And when carefully questioned we find out that the surgery was carried out by some doctor who was not even trained to do nasal surgery.

The most common reason for nasal obstruction (clogged airways) is a deviation of the nasal septum.  The second most common cause is swelling of the inferior turbinates.  Most people have some degree of septal deviation which is asymptomatic, meaning that it does not cause any obstructive symptoms.  And there are many people who have swollen inferior turbinates, which often times is confused with “polypRecovery from Nasal Surgery Images”.  However, if these problems are not paid adequate attention to and are not properly treated, there is a good chance that with cosmetic nasal surgery the obstruction will manifest itself and the patient will end up having breathing difficulty through the nasal airways.  This is probably the most common reason for a secondary surgical revision of the nose.

Who can perform nasal surgery?


Therefore, it is very important for the surgeon who claims to be able to carry out nasal surgery to have adequate training and experience in dealing with all problems related to the nose.  Unfortunately with the freedom of advertising in medicine there are many unqualified individuals who portray themselves as “experts” in nasal surgery without having a clue as to what nasal surgery entails, and people often are confused and do not know the difference because of misinformation and deceptive advertising.  A properly trained, qualified, and certified plastic surgeon will first evaluate the patient’s nasal airways and determine whether there is anything that needs to be treated or corrected.  In our practice patients are almost always placed on nasal decongestant treatment prior to surgery, and almost 50% of the patients undergo cosmetic nasal surgery in conjunction with correction of a deviated septum.  Swelling of the turbinates is less frequent and most of the time responds to medical treatment.  However, there are rare occasions where the turbinates have to be reduced surgically.

It is for these reasons that over the past 30 years we have only had a few patients who required airway revision after nasal surgery.  Nasal surgery is definitely one of the most technically demanding fields in plastic surgery and people need to make certain that their surgeon is certified by the appropriate board, American Board of Plastic Surgery, or American Board of Otorhinolaryngology, and has adequate experience in all aspects of nasal surgery.

SCARRING AFTER PLASTIC SURGERY, CAN IT BE CONTROLLED?

SCARRING AFTER PLASTIC SURGERY, CAN IT BE CONTROLLED? image

SCARRING AFTER PLASTIC SURGERY, CAN IT BE CONTROLLED?

Many clients refer to us with the notion that plastic surgeons are able to somehow, miraculously, remove a hanging belly or excessively heavy breasts without leaving any foot-prints behind, i.e. with no scars!  Then when we explain to them that there are scars involved which are unpredictable they are often taken aback.  Most people come to accept this and go ahead with the surgery, but there are some who ponder on this and end up going from one plastic surgeon to another, trying to find someone who will “guarantee” that they will not have any scars.

Guaranteeing Plastic Surgery Without Scars

Of course all board-certified plastic surgeons would tell patients the same thing regarding scarring, but those individuals who are looking for someone who will “guarantee” that they will not have scars might fall into the trap of unqualified individuals with no training and experience who claim to be able to do such complex plastic surgery procedures and who will give such patients an actual guarantee.

Who Can Perform Plastic Surgery?

We have seen many patients who have fallen into such traps.  Why?  Because unfortunately in the U.S. advertising is allowed in medicine, and in most states once you obtain your license to practice medicine legally you are allowed to do anything and perform any surgery.  So, there are many individuals CAN PLASTIC SURGEONS MAKE SCARS DISAPPEAR? imagewith no training in plastic surgery who claim that they can carry out plastic / cosmetic surgery procedures.  Such individuals are experts at only one thing:  Giving misleading information along the lines of what the patient wants to hear, such as “oh yes its an easy operation”, “you will have no scars”, “you’ll be up and about in one day”, etc. etc.  Some people may remember the glamorous infomercials of “Lifestyle Lift”, and some may have followed the news as to what happened to that house of deceptive advertising.  If you don’t, here is a link:

Ask.com/Lifestyle Lift Lawsuits

The result of such deceptive practices usually is the horror stories and botched up patients that most people have heard about.  We have seen many patients who tell us that they only found out after being botched up that their so-called cosmetic surgeon really had no training in plastic / cosmetic surgery.  So the consumer has to be diligent in adequately educating themselves as to who is qualified to perform plastic / cosmetic surgery procedures.  Please visit our blog on this topic http://www.rubenabrams.com/choosing-plastic-surgeon/

At any rate, under ideal circumstances and in experienced hands, it is the person’s own body that determines how visible or inconspicuous scars will be.  Most plastic surgery procedures involve the longest and most extensive incisions in surgery.  But we have patients in whom you need a magnifying glass to see their scars, and we have others who have more conspicuous ones. 

Treating Scars After Plastic Surgery

In our experience, the only thing that has actually made a difference in the scars resulting from our procedures is continuous taping with special scar tape for a period of 3 months.  How this tape works will be discussed in a later blog, but for now suffice to say that we have actually seen much better scars following this procedure for the past 10 years.  After the 3 month period of course there are many products on the market and we have ones that we recommend, but eventually it is the person’s own genetics that determine how visible the scars will be.  One thing is certain and that is that scars improve with time.  Many patients have quite visible scars after 6 months, but at two years their scars have faded and are barely visible.

CAN PLASTIC SURGEONS MAKE SCARS DISAPPEAR?

CAN PLASTIC SURGEONS MAKE SCARS DISAPPEAR? image

CAN PLASTIC SURGEONS MAKE SCARS DISAPPEAR?

Over the past few decades the general public’s education in medicine has increased tremendously, thanks to the internet and popular TV shows that focus on health information.  However, there are still patients who refer to us requesting the total removal of scars resulting either from an injury or previous surgery.  We also have patients coming in for a certain procedure, for example a Tummy Tuck, and they get disappointed when they are told that there is scarring involved.  Sometimes they react by saying things like: “…aren’t plastic surgeons supposed to do surgery without leaving scars?”

WHAT ARE SCARS?

Well, lets first talk about eliminating scars.  What is scarring?  The body heals wounds by forming scars.  If the body did not do that obviously all wounds would remain open.  As soon as there is a break in the continuity of tissues anywhere in the body, skin, muscle, bone, etc., the body starts bringing building material that is needed for repair of that wound.  Scar is a result of that repair.  This scar varies tremendously depending on the area,
the mechanism of injury, the presence or absence of infection, and most importantly thTummy Tuck Risks Imagee individual’s genetics.  Scars are permanent.  In most cases they get better with time, but there is virtually no procedure that can totally eliminate them.  The reason is simple.  If you remove a scar and repair the area, you will re-initiate the scarring process.  Granted, under certain circumstances the resulting secondary scar may be improved, but in many cases the secondary scar may be the same or even worse.  Scars can only be improved by plastic surgeons under certain circumstances either for functional or for cosmetic reasons.

PLASTIC SURGERY AND SCARS

Now, as for scars resulting from plastic surgery procedures.  Plastic surgery procedures mostly involve the most extensive incisions and hence the most extensive scarring.  We see many patients who come stating that their friend had a certain procedure and “you can’t even see the scar”.  A lot of time goes into explaining to these patients that individuals scar differently.  If the same operation is done in ten individuals we are likely to see ten different types of scars.  In one person the scar may be totally invisible requiring a magnifying glass, in another it may be stretched and “hypertrophic“, and in the rest it may be anywhere in this range.

Plastic surgery does not mean performing “scarless” surgery.  It means knowing where and how to place scars for the most optimal and most acceptable functional and cosmetic outcome.  The rest of the scarring is carried out by the individual’s genetics.  However, there are things we have available to help minimize scarring.  Certain types of tape and certain scar gels are some of these measures.  Through the regular and vigorous use of these measures we have been able to significantly improve the type of scars that we see after plastic surgery procedures.

FAT INJECTION / FAT TRANSFER – TEN YEARS DOWN THE LINE

FAT INJECTION / FAT TRANSFER - TEN YEARS DOWN THE LINE image

FAT INJECTION / FAT TRANSFER – TEN YEARS DOWN THE LINE

Early History

Using a person’s own fat as a filler or to augment certain parts of the body is a fairly old concept.  As a matter of fact there are reports that the first attempts at enlarging breasts were done using one’s own fat in the latter parts of the 19th century.  Of course this was doomed to failure because of poor technology, poor understanding of fat physiology, unsterile operating environments.  Obviously fat transferred under these circumstances would either get absorbed quickly or become infected.

Recent History of Fat Transfer

In the 1980’s a few plastic surgeons started experimenting with fat transfer for breast enlargement.  But because the methods were not adequately scientific and did not go through the rigorous peer review required by the scientific community, the procedure was not accepted by the plastic surgery community and fell into disfavor.  Until this time it was thought that fat cells would not survive transfer and translocation.  But this logic belonged to the pre-liposuction era.  With the coming of liposuction and the possibility to aspirate fat in the form of an emulsion consisting of liquid and fat cells, it became apparent that these fat cells could actually be injected into certain areas with a fairly reliable and predictable viability.

Current Research

Shortly thereafter thorough research on fat transfer, its short-term and long-term viability, safety, and benefits began in a scientific manner.  Through this research it was shown that fat cells that were aspirated by liposuction and then injected into other parts of the body do survive for months and sometimes even years.  As a matter of fact many researchers found that the fat cells not only survive but regain their blood flow, to the point where if the person gains weight the areas where the fat has been injected will also gain in size.

Clinical Trials

STORY BEHIND LIPOSUCTIONAfter these preliminary researches, plastic surgeons put the technique of fat transfer to clinical use and started conducting short-term and long-term clinical studies.  In the beginning the fat transfer technique was mainly used for correction of deformities and depressions, either congenital ones, or those created during older techniques of liposuction.  Through experimentation many new techniques and equipment were developed for safer and more predictable fat transfer.  The procedure eventually came to be known as AUTOLOGOUS FAT TRANSFER (AFT) and the more modern techniques prompted the term MICROFAT GRAFTING to be coined.  One can safely say that the modern era of fat transfer and fat grafting began 10 years ago.

During the past ten years the procedure has been used for many different purposes with demonstrable results up to ten years.  Breast Enlargement, Buttock Enlargement, Facial Rejuvenation (Correction of hollow cheeks, chin augmentation, elimination of lines and depressions) by Volume Restoration are some of the main areas where AFT is currently being used successfully.

Most studies indicate that an average of 30% of the fat that is injected gets absorbed and that is why in most cases people need a touch-up after a few months.  One exciting area in this area is the development of techniques for increasing the long-term survival of fat cells using REGENERATIVE ADIPOSE CELL ENHANCEMENT.  This involves separating stem cells from a separate batch of fat aspirated from the individual and adding them to the fat that is being used for injection.  Preliminary results indicate that a much larger percentage of the injected fat can be expected to survive with the aid of this technique, thus possibly eliminating the need for touch-up injections.

As can be seen this is a totally new area in plastic surgery and there is ongoing research taking place in all parts of the world.  There will certainly be further developments and discoveries in the coming months and years.

HEALTHY EATING VERSUS “DIETING” – PART 3

HEALTHY EATING VERSUS "DIETING" image

HEALTHY EATING VERSUS “DIETING”

As everyone knows, our goal in our profession is to help our patients lose weight and stay in shape, either before or after surgical procedures that we carry out.  We have previously discussed how important it is for patients to be as close to their ideal weight as possible with an acceptable BMI before surgery.  Most of our patients are unfamiliar with the concepts in healthy eating that we teach them.

There are a few basic principles that we teach our patients and this system is something that has worked for me and everyone I have taught it to ever since medical school.

1. Contrary to what most people think, starving yourself is the absolute worst way to try and lose weight.  It never works.  As a matter of fact it back fires becuase it only results in binging when you sit down to eat.  So the first principle is to have not 3 meals but 5 meals a day.  The philosophy behind this is simple.  When you sit down to eat you don’t feel very hungry so you get satisfaction with a small portion. Therefore 5 small portions is much healthier than 3 large portions.  It may be a little difficult in the beginning to get used to this, but after a while your stomach gets reprogrammed to feel full with a small portion.HEALTHY EATING VERSUS DIETING WHY GRAIN IMAGE

2. So what do we recommend to eat at those 5 meals.  These meals should consist of grilled white meat, occasional (once a week) red meat if your heart desires, vegetables, fruits, small amounts of whole-wheat bread (or preferably gluten-free bread), small amounts of brown rice, quinoa, corn, small amounts of gluten-free pasta, preferably quinoa or corn based pasta.  Conventional pasta is much more fattening and unhealthy because of its high load of conventional flour and eggs. 

3. Plenty of water, herbal tea, fresh fruit juices, smoothies made of fresh fruits and vegetables.  Absolutely no sodas, “diet” sodas, or anything containing unnecessary carbohydrates and poisonous sugar substitutes such as high-fructose corn syrup.

The details of these healthy eating instructions are available at our office and they can be tailored to each individual’s needs or likes and dislikes.