Dr. Bruce Blogs

Opening remarks

Well, here goes. My foray into the world of blogdom and this is the first post. I think it's appropriate that I maybe start with explaining just why I thought it was worthwhile to do this blog.

My intent is to offer some insight into the world of plastic surgery and cosmetic non-surgical options. There always seems to be a great deal of interest in these topics whenever I am in a group at a party or other social gathering; a natural curiosity because of the mystique around the procedures themselves and sometimes the people who get them. Unfortunately of late, there has been a great deal of misinformation and poor depiction of plastic surgery on such programs as Nip/Tuck and Dr.90210. (Dr. Rey and his cohorts on that show aren't even board certified plastic surgeons!--not by a legitimate board anyway-- this will be a future blog topic)

I've been in private practice in plastic surgery on the north side of Indianapolis for the past 22 years. I strive to give my patients the best results available, with minimal downtime, utilizing the best practice techniques currently available. My patients will tell you that I am a straight shooter, sometimes brutally honest, but always keeping their best interests at the forefront. I will endeavor to bring that same patient-focused approach to this blog. Hopefully some folks will find this beneficial. If I'm not doing a good job, please let me know.

The Right Reasons For Liposuction

I often see patients in Indianapolis who tell me they want to have liposuction to get rid of their cellulite. I hate to be the bearer of bad news, but liposuction is a sculpting procedure that will improve and contour your shape in particular areas of the body. But, it does not get rid of or diminish cellulite.

There is absolutely no product or treatment currently available that gets rid of cellulite. Trust me -- if it existed, I'd be using it! Just because you see magazine and television ads touting this serum and that procedure, does not mean that it's effective or even safe.

The perfect liposuction candidate is someone who has good skin tone and wants to reduce fat that has caused their body to look disproportionate. Liposuction is commonly performed on the thighs/saddlebags, buttocks, hips, flank and abdomen. I also do this procedure in conjunction with most of my tummy tucks to improve the overall contour of the abdomen. I currently use a technique known as SAFELipo to do liposuction. This is explained in more detail on my website, and it allows me to get much better contouring and shaping than any technique I have used in the past.

Imagine being comfortable wearing a new bathing suit to the pool, a pair of shorts to the gym or a body-hugging dress in the summer. It's such a liberating feeling when you are able to confidently show off your figure!

When searching for a liposuction surgeon in Indianapolis, it's important to choose someone who is board certified in plastic surgery by the American Board of Plastic Surgery and performs this procedure on a regular basis. Don't be afraid to ask to see multiple before and after photos. I cannot tell you how many patients have come to me following a "botched" liposuction procedure that has been disastrous -- because they went to an OBGYN or family physician who is dabbling in plastic surgery. I covered this topic in my earlier "Buyer Beware" post.

Remember, when you have this procedure, you are changing the look and composition of your body and undergoing anesthesia. Do your homework ahead of time, ask to see before and after photos, and don't go to someone because they have the lowest price. You may end up paying twice as much if the surgery has to be redone.

 

The Effects of Pregnancy following Breast Augmentation

Breast augmentation is a mainstay of my Indianapolis area cosmetic plastic surgery practice. In a recent post I discussed the issues of breast feeding following breast enlargement. In this post I would like to discuss the potential impact of pregnancy on a previously augmented breast. This too is a frequent topic during consultations.

The truth is there is no consistent impact of pregnancy on a previously augmented breast. There are so many factors at play here: How big was the augmented breast prior to pregnancy? How large will the patient's actual breast tissue increase in size when her milk comes in? What is the genetic elasticity or "stretchiness" of her skin and tissues? How much weight was gained with the pregnancy? One myth I would like to dispel: I do not believe that breast feeding per se, stretches a woman's skin and breast tissues more than they would be with just her milk coming in. I've seen patients who never breast fed who have very stretched out breasts just with the changes of pregnancy and the milk coming in. Similarly, I've seen women breast feed for a year or longer without significantly stretching out her tissues. In fact, one of my patients who had augmentation before pregnancy, breast fed twins for one year and reported that her augmented breasts looked great when she finished breast feeding!

The reality is that no one can predict the exact changes that may occur to an augmented breast following a pregnancy, with or without breast feeding. I don't personally believe that there is any reason a woman should necessarily put off having breast enlargement until after having children. In fact, I would argue that if a woman wants to increase her bust size while she is young and has the rest of her figure intact, go for it! This is clearly a personal and individual decision each woman must make.

If there are going to be significant changes following childbirth to a woman's breasts, chances are those will happen with or without implants. One caveat: since I don't place implants larger than an individual woman's tissues can handle, there is a chance that I may see less "stretch damage" from pregnancy in my patients than someone who routinely puts in larger implants does. There clearly are physical limits to what the tissues can handle.

Fat Grafting-- The Ultimate Filler for Face, Breast and Body

I am writing this post to update my experience and feelings about the use of a patient's own fat as a filler material. I have been aggressively using fat for the past couple of years to restore fullness to faces which have deflated with age. Virtually every case of facial rejuvenation surgery I now do includes some fat grafting. Through improvements in technique and with the use of the Brava device for pre-expansion we are now able to do breast augmentation using fat, or lipoaugmentation of the breast with excellent results in a single surgical procedure. Fat grafting is also being used to repair overdone liposuction, often by non-plastic surgeons, and to fill defects following trauma or surgical procedures.

There will follow additional posts which will go into more detail on each of these areas of using autologous fat, which is a patient's own fat, as a source of restoring volume. We will discuss the use of fat to rejuvenate the backs of hands which can look thin and veiny with age. I will also go into detail as to the possible beneficial effects of stem cells contained in fat on the tissues surrounding the grafts.

Let me say that to date, I am highly encouraged by the clinical results I'm seeing with using a patients own fat as a filling agent. Although we need more data, it appears that the grafted fat that does "take" or remain following grafting is very long lasting, possibly permanent. This beats any synthetic filler or breast implant by a long way! Stay tuned for more exciting news about the benefits and positive clinical results from autologous fat grafting.

Breast Feeding after Breast Augmentation--the facts

Since breast augmentation is a significant portion of my Indianapolis area cosmetic plastic surgery practice, the issue of breast feeding after breast augmentation frequently comes up during consultations. First, I want to be on record as being a HUGE fan of breast feeding. I am continually amazed at the large number of studies in the medical literature supporting multiple benefits associated with breast feeding -- preferably for up to a year. I always encourage all of my patients contemplating having children to do their best to breast feed. The plastic surgery literature is also definite on the fact that having breast augmentation does NOT interfere with the ability to breast feed. Also, despite some old unfounded statements to the contrary,there is no contamination of breast milk from silicone gel filled implants. It is important to realize that despite their best intentions, some women simply are not able to successfully breast feed, implants or not. The presence of implants does not in any way increase the chances of having problems nursing.

We place our implants under the pectoralis muscle with only the bottom portion of the breast tissue in contact with the implants. When a mother's milk comes in,the gland tissue above the muscle is producing milk.This breast tissue is on top of the muscle with the implant underneath. Also, it is important to remember that the materials implants are made of, silicone outer shells and silicone gel filler, are inert -- multiple studies have demonstrated that there simply is no breakdown of this material by the body.

Women can have implants placed prior to childbirth and breast feeding without concern for any negative impact on their ability to nurse. In an upcoming post I will discuss the impact of pregnancy following augmentation on the breast tissues and the possible changes to breast size and shape that can result.

An Effective Non-Surgical Facial Treatment

I am never one to try the latest “gimmick” when it comes to cosmetic plastic surgery and esthetics. And, believe me, there are many of them out there that I see every day – often times because patients come to me to repair the damage. Remember, just because you see a treatment or procedure touted on national television does not mean that it works or is safe. I find that one non-surgical procedure we are using is often very successful in tightening facial tissues. It’s called Ulthera.

This is a non-invasive procedure utilizing sound waves to lift, tighten and tone loose skin on your face and neck. It increases collagen production, which enables the skin to continue to have a younger look and smoother texture. What is unique about Ulthera is it’s the only non-surgical procedure that goes deep down into the areas of the skin where I normally suture during a facelift.

Even better, there’s no anesthesia or downtime, and results are long-lasting – often 12-18 months. You can actually drive yourself home or back to work after your appointment. It only takes a few minutes per area that is treated.

Everyone is different, but patients typically need one or two treatments.

Alure Suture Suspension Breast Lift

I am posting this as a preliminary announcement of a new technique we have been using quite a bit lately that adds to our plastic surgery "toolbox". In early February at a major national plastic surgery meeting, a colleague of mine, Dr. Jack Fisher, of Nashville Tennessee presented a paper entitled: "Scarless Breast Lift" in which he presented data about an exciting new device made by Alure Medical which utilizes permanent suture material to lift breast tissue. I can tell you that we have long been frustrated in our attempts to achieve fullness of the "upper pole" (top) of the breast when doing breast lifts (mastopexy) or breast reductions. For many years I have told patients that the only truly reliable method of maintaining fullness at the top of the breast was to place an implant. In many cases patients neither wanted or needed the extra volume of an implant and therefore were left without any good options. The reality of the effects of gravity and tissue stretch is that no matter how much I would push the breast tissue up and tighten the skin in a mastopexy or breast lift procedure, physics would eventually win out. We even tried a surgical technique called: "suture shaping" but found that gravity still won out to some degree.

The concept of the Alure suture suspension system is to place a piece of permanent suture material transversely beneath the pectoralis fascia a little below the collarbone and then to pass two sutures down vertically through the breast tissue which contain barbs again made of permanent suture material. When the vertical sutures are pulled up they grab the breast glandular tissue and then are tied to the transverse suture on either side creating an internal "upsidedown U" in the tissues. The knots are barely palpable at the top and the effects appear to be long lasting although it should be pointed out that since this device hasn't been around very long we really don't know just how long it will maintain the effect. Dr. Fisher presented a minimum of 1 years of followup on each patient.

Complications appear to be few and minimal. The material doesn't show up on mammograms. We have been using this device for the past few months and I will update our progress in a few months. So far, so good though, with good patient satisfaction.

Awake Breast Augmentation-- the real story

Ladies, beware of a procedure known as “Awake” breast augmentation surgery. This procedure is done in an office setting (as opposed to a surgery center) and uses only local anesthesia – thus the term “awake”. Most importantly, the physicians performing most of these surgeries are not even surgeons. Many of them are OBGYN doctors. To me, this is incredibly scary. As a plastic surgeon, would you want me doing your gynecological exams and delivering your babies? I think not!

 

In my opinion as an experienced, board certified plastic surgeon who does multiple breast augmentation surgeries every week, this is bad business and certainly not in the patient’s best interest. What happens if something goes wrong during the procedure? Patients are in an office setting – with no anesthesiologist or surgery staff present. As it is, breast augmentation has the highest complication rate of all plastic surgeries performed by board certified plastic surgeons. So, I have to wonder what type of complications we will see with this Awake procedure – especially when being performed by non-surgeons in unsafe surroundings.

 

Personally, I would never perform plastic surgery in an office setting. These procedures should be done in a certified outpatient plastic surgery center that is properly staffed with anesthesiologists and plastic surgeons who are board certified in their respective specialties and employ staff who are highly trained and work in surgery every day.

 

If you are considering breast augmentation surgery, seek out a plastic surgeon who is board certified by the American Board of Plastic Surgery, performs multiple surgeries of this type on a regular basis and can show you before and after results that meet your expectations. Don’t skimp. You have to live with this surgery for the rest of your life.

 

FDA Hearing on Breast Implant Followup Studies

The FDA has scheduled a hearing for August 30 and 31, 2011 to address the issue of post-approval long-term breast implant studies. In 2006, the FDA released silicone gel-filled breast implants back onto the market. As a condition of this release however, the agency required the two manufacturers of these devices, Allergan and Mentor, to conduct ongoing studies to collect data from patients for 10 years following implantation. These studies were intended to collect data on complication rates, risk of neurological disease and suicide, cancer rates, issues with mammography, and potential problems with lactation and reproduction. Additionally, the FDA strongly urged surgeons to recommend that patients undergo an MRI of the breast implants 3 years after the initial placement and then every two years thereafter. The intent of the agency I believe was to have ongoing monitoring of silicone gel-filled implants to try to capture any potential problems that may not have surfaced during the rigorous ten year duration pre-approval studies. They seem to be very concerned about the issue of "silent ruptures" of the devices which in many, and in fact probably most, cases generally goes undetected as long as the surrounding scar capsule is intact.

What the FDA doesn't seem to realize in my opinion, is that these proposals are a significant burden to patients and their surgeons. For the patients to come in to the office yearly to be checked and complete paperwork is not an insignificant inconvenience to the majority of implant recipients who are juggling child care and often a job simultaneously. Then to add insult to injury, they are requesting the patient get these MRI's which they would have to pay for out of pocket-- an expense that could easily run anywhere from $1200-$2000 every other year! It is my humble opinion that these bureaucrats are truly out of touch with the realities of these real world patients. On top of that, even if the patients got the requested MRI and there was an intracapsular (inside the capsule) leak suggested, I would not recommend removal at that point unless at some point the capsule tore and the gel escaped into the surrounding tissues. In my rather extensive experience, many women go for years with ruptured implants contained by the scar pocket without any problems.

My colleague Dr. Caroline Glicksman from the NY area has wisely suggested that the FDA consider some other less onerous methods of collecting information such as via an online questionnaire. I suspect the percentage of compliance would be much greater. I would hope that the FDA would rethink their request for the serial MRI's and recommend them only if the patient is in some way symptomatic.

I have worked extremely hard in my practice to reduce complications associated with breast implant surgery and to maximize good patient outcomes. At the same time I have always tried to be realistic and mindful of avoiding any undue inconvenience for my patients. It is my sincere hope that the FDA will do the same.

If you would like to offer your opinions on this topic to the Center for Devices and Radiological Health (CDRH), the FDA committee charged with oversight of breast implants, you can email your thoughts to them at the following address: http://www.regulations.gov

More Success with CoolSculpting by Zeltiq

We have now had our CoolSculpting machine by Zeltiq for 7 months and I'm happy to report that we are seeing consistently good results. The key is proper patient selection which is why I insist on seeing each of these patients myself before treatment. Unfortunately, some doctors are sending these patients to a technician/esthetician in their office without seeing them themselves. The result is that some of these patients will receive the Zeltiq treatment when they really might be a better candidate for some other procedure, leading to a disappointing result.

I am including an example of a three month post-treatment result in this post. This patient has had only one treatment, but could have a second treatment if desired.

More examples of before and after photos can be found at our website page for Zeltiq. While most of our treatments have been of love handles as shown above, abdomens, medial thighs and bra fat are frequently being treated as well. We have also treated breasts in a few males with good results and now in a couple of female breasts as well.

We are anxiously awaiting a new applicator that will expand our treatment areas especially for arms. Once again, the CoolSculpting treatment isn't for all areas or for significant fat reduction. It does work great for an area as shown above. No incisions and no downtime make this treatment especially appealing. It has been a great addition to our offerings of noninvasive treatments in our practice.

CoolSculpting by Zeltiq followup

In an effort to keep information current on CoolSculpting by Zeltiq, I wanted to let people know that we are seeing many of our initial patients in followup and are seeing significant reduction in the areas treated. Unlike so many other new technologies where results are not consistently seen, if an area of excess fat is treated with CoolSculpting then we are seeing a 100% response--usually with 20-30% reduction of the fat volume.I am usually skeptical of claims made by many new companies, especially when it sounds just "too good to be true", but I can confidently say that this treatment, in properly selected patients, consistently delivers excellent results. The thing we are seeing is that patients are attracted to an easy option to reduce problem areas that maybe wouldn't justify a trip to the operating room, with absolutely no down time. It is important to understand that in order for an area to be amenable to treatment, you must be able to grasp the fatty area in your hands-- therefore we usually can't treat areas such as saddlebags where the skin is often too tight to allow the machine to "grab" the tissue. Ideal areas are the stomach, hip rolls, bra fat and sometimes medial thighs.I am engaged in a study with the Zeltiq company right now evaluating this as a possible treatment for gynecomastia, or excess male breast tissue. If you would like to learn more go to: chillmyfat.com.