Here’s an eye-opening study published in the recent issue of Lasers in Surgery and Medicine, comparing the efficacy of laser-assisted lipolysis using various fat-busting lasers, including the first generation SmartLipo and CoolLipo machines (10 watts power). The authors are respected laser experts from La Jolla, California.

Liposuction of the arm was performed, using tumescent technique, with one of three fat removal devices, and the results were evaluated at 1 week, 1 month, and 3 months post-operatively.

In the first comparison between SmartLipo and standard non-laser liposuction, no significant improvement of results over tumescent liposculpture alone was noted using the 10 W Smart Lipo laser.

The second study showed no difference using the 10 W SmartLipo device versus the 10 W CoolLipo laser-assisted lipolysis system.

Finally, the multiplex (combination) 1,064/1,320 nm system appeared to show improvement in skin laxity and fat reduction. However, more complications were seen, with intra-operative thermal burns in 2 of 20 patients using the multiplex system.

Comment: Of course, the laser manufacturers now have increased the power of the laser lipo machines. While this may melt fat more effectively, it also increases the potential for thermal injury. We’ll have to see whether the newer, more powerful machines can be actually proven to show a significant difference over standard non-laser liposuction in an objective study. It’s great to finally see some science looking at this.

I feel bad for the physicians that spent a lot of money on the first generation (10 watt) machines – they got conned by the lure of new “laser” technology and didn’t wait for the scientific proof.

It’s seems like a perfect answer – “take a little off down here, put some a little more up here”. But fat grafting to the breasts has been controversial. A problem, known as fat necrosis, has been the #1 concern. Lumpy deposits of injected fat, which may feel exactly like a breast cancer, can result if the fat does not survive the transfer, and goes on to form calcified scar tissue within the breast.

Previously, back when radiologic imaging of the breast was less advanced, sorting these lumps of scar out from early breast cancers was a real problem. Surgical biopsies were sometimes needed to make the determination. Over the last decade, though, a lot of work has been done on fat grafting, reappraising its role as a reconstructive tool. Here in the U.S., Drs. Coleman and Khouri, two plastic surgeons who have been independently making major contributions to this area, deserve a lot of credit.

In this month’s issue of the Aesthetic Surgery Journal is an important study looking at the safety of fat injection to the breast. This work, from Lyon, France, summarizes 880 procedures over 10 years, and mainly looks at the application of fat grafting for reconstructive applications – following mastectomy reconstruction, and for breast asymmetries and other developmental problems.

The French group in the study used Dr. Coleman’s technique (low-pressure small cannula liposuction of the fat from the donor area, purifying the fat with a centrifuge, then injecting it in very small volumes into the target area). None of the more advanced techniques that have been recently reported to enhance fat grafting success were used -i.e. no addition of stem-cells, or use of the external BRAVA suction device.

Very careful breast imaging was mandatory – both pre-op and at one year post-procedure, using mammograms, ultrasound and MRI. The French radiologists “signed off” on the normal status of the exams before the patient underwent surgery. (I wonder if any lawsuit-averse U.S. radiologists would be willing to do that!) While all patients had some post-surgical changes in their post-op mammograms, the radiologists were, in general, able to sort out these changes with the use of the more advanced imaging methods and a lot of experience.

Ninety percent of the results were rated as either “good” or “very good”. As expected, the surgeons found that about 40% of the injected fat melted away. Fat necrosis – formation of lumpy scar tissue – was seen in 15% of the authors first 50 cases, decreasing to about 3% after that. In some cases, a needle biopsy of the lumps in the breast was still required.

Overall, good improvements in the breast contour and degree of symmetry were reported, and the authors felt that fat grafting represented a very good technique for “touching-up” results after a complex breast reconstruction, or avoiding a more-complex reconstructive method. They also showed nice results for breast asymmetry and cases of Poland’s syndrome, a developmental breast problem.

Bottom line: fat-grafting to the breast is a procedure which, while very promising, is still under development. Guidelines about timing, indications, pre-op and post-op MRI imaging, and important details regarding the best technique are still being sorted out. I can not yet recommend it for cosmetic breast enlargment at this stage, outside of a carefully controlled clinical trial.

About a year or two ago, a new type of LED device started appearing at the various plastic surgery meetings. It was suggested that certain frequencies (colors) of light could have beneficial properties on the skin, through a theory known as photomodulation. There was no heat, no pain, no downtime, no complications… Sitting under a bank of pulsing colored LED’s for a short treatment was supposed to improve your skin.

Well, longtime readers of this blog will begin to notice their noses twitching. We’ve often commented “when you do less, you get less”. So how could this low-power, non-thermal photomodulation thing work?

A group of investigators from the Massachusetts Eye and Ear Infirmary tried to confirm some previously published good results on the GentleWaves LED system, which uses an amber LED bank for facial skin treatments. Good scientists regularly do this – confirming earlier experiments. But something surprising happened. I’ll let their abstract published earlier this year in Dermatologic Surgery tell the story…..

“METHODS AND MATERIALS: Facial skin was exposed to pulses of 588+/-10-nm-wavelength light from a photomodulation device for 40 seconds once a week for 8 weeks. Photographs, clinical assessment, and a subjective questionnaire were taken at baseline, at the last follow-up, and 1 month after that. Thirty-six patients’ pre- and post-treatment photos were arbitrarily scrambled, and 30 independent blinded observers were asked to pick the post-treatment photo. Two time-point comparisons were evaluated.

RESULTS: For every facial characteristic studied and for both time-point comparisons, patients reported highly statistically significant improvements. In extremely sharp contrast, neither the physician’s assessment nor the independent observers’ evaluation indicated any improvement.

CONCLUSION: Patients genuinely believed that several of their facial features had improved, even though there was no detectable objective change. Our data therefore suggest that the LED photomodulation treatment from the device tested is a placebo.”

Take-home lesson: This device was FDA approved. This means it is safe, as in non-damaging. FDA approval of devices, unlike FDA approval of drugs, does not imply that the device is effective. Gentlewaves LED photomodulation device appears to be hype. Don’t waste your money.

Lesson #2: when reading scientific studies, look for objective evidence of improvement – rather than just the subjective opinions of the patients’ themselves.

As one of the busiest breast surgery practices in Central Florida, I see many patients who would like a breast augmentation performed. As part of our routine, we carefully examine the patient, and during our examination, it’s very common to find several differences or asymmetries between the two sides.

Most patients have no idea about these minor asymmetries of the breast until we show them…and then they see them. The reason we do this, of course, is to explain that these asymmetries will still be there post-operatively after a standard breast augmentation operation, since they were present pre-operatively.

There are several interesting studies about pre-operative asymmetry in patients undergoing breast augmentation.

Rohrich, Hartley & Brown, in their 2003 review of 100 patients, published in Plastic and Reconstructive Surgery found:
– 88% of women had natural breast asymmetries when critically examined,
– 72% of these women had more than more asymmetric feature.

In other words, nearly nine out of ten women have some degree of breast asymmetry. We commonly say “Think of the two breasts as sisters, not identical twins!”

Common asymmetries in this study included:
– nipple / areola position differences in 53%
– breast volume differences in 44%
– infra-mammary fold position differences in 30%
– chest wall (bony) differences in 9%

Similar findings were seen in 2009 study by de Chardon and associates, who examined 200 breast augmentation patients. They found a higher incidence of chest wall asymmetries, at 17%, which was most commonly caused by scoliosis of the spine with secondary changes in the rib shape.

Perhaps the most interesting finding from this French study was, of the patients that complained about breast asymmetry after surgery, 83.3% (five out of six) of them had the same asymmetry pre-operatively.

This finding certainly indicates the need to explain to patients what is present prior to the implant surgery, and help the patients to understand which features can or can not be corrected by implants alone.

The most important educational meeting for aesthetic plastic surgeons, in my opinion, is the ASAPS annual meeting. It’s happening next week – and yours truly will be there. We’ll hear “what’s hot”, “what’s new” and “what’s not working”. All of the “major league” players of aesthetic plastic surgery will be there, discussing the best ways to do facelifts, rhinoplasty, eyelid surgery, breast surgery, body lifts, as well as fillers, peels and lasers. A huge vendor display area allows attendees to see many new products as well.

My favorite sessions are the panels, where experts – often with conflicting opinions – debate the merits of their particular approach.

I’ll be taking my notebook with me – and should have plenty of hot & juicy plastic surgery news to blog about!

Here’s some interesting data from a press release from the American Society of Plastic Surgeons:

“Faced with news of difficult economic times, and a belief that hiring is based on looks, millions of American women are looking at cosmetic medical procedures to give them a competitive edge in the workplace. In a new telephone survey compiled by the American Society of Plastic Surgeons (ASPS) of 756 women between the ages of 18 and 64, many reveal cosmetic plastic surgery procedures now appear to be an important rung on the success ladder.

– 13 percent (more than 1 out of 10 of the 115-million working-age women) say they would consider having a cosmetic medical procedure specifically to make them more confident and more competitive in the job market.

– An astounding 3 percent (nearly 3.5-million working women) say they’ve already had a cosmetic procedure to increase their perceived value in the workplace.

– 73 percent (almost three out of four or, 84-million working women) believe, particularly in these challenging economic times, appearance and youthful looks play a part in getting hired, getting a promotion, or getting new clients.

– 80 percent (four out of five or 92-million working women) think having cosmetic medical procedures can boost a person’s confidence.”

Actually, this trend is not really that new. Men have been coming to me for years, getting their upper eyelids fixed, so they don’t look like the “sleepy, old-guy-past-his-prime”. Executives often have specifically told me that they want to look more like their youthful and energetic business competition, and want to have surgery to give the appearance of still being in their prime, rather than being perceived as being “tired” or “over-the-hill”.

Investing in yourself is always a wise investment!

According to a report on the health page of the BBC news website, new research suggests that mental powers start to dwindle at age 27, after peaking at age 22.

Professor Timothy Salthouse of Virginia University tested 2,000 healthy people aged 18-60. Study participants were tested with puzzles, word recall and spotting patterns in letters and symbols.

In the majority of tests, top performance was achieved around age 22.

In tests of brain speed, reasoning and visual puzzle-solving ability, declines in performance began at age 27. Memory testing started to decline at age 37, while vocabulary and general information held steady until age 60. Yikes !!

In other words, we may need to start anti-aging treatments earlier than previously thought!

New, in this month’s issue of the Plastic & Reconstructive Surgery journal, is the 10-year update on the famous twins study, originally devised by Dr. Bernard Alpert at UCSF.

In this study, 2 sets of identical twins underwent facelift procedures, by four master surgeons, all using different facelift techniques. The goal was to see which facelift technique worked better.

For those of you who like the details, the surgeons and their techniques were:
Dr. Jack Owsley — multi-vector SMAS-platysma facelift with neck liposuction,
Dr. Dan Baker — SMAS-ectomy with anterior platysmaplasty,
Dr. Sam Hamra — composite / deep-plane facelift with anterior platysmaplasty,
Dr. Oscar Ramirez — subperisoteal facelift with anterior platysmaplasty.

(N.B. platysmaplasty is a necklift operation, done with an incision beneath the chin area, tightening the neck muscles together in the middle.)

Drs. Baker and Hamra were assigned the first set of twins, while Drs. Owsley and Ramirez worked with the second set of twins.

So, which facelift method was the best?

Well – the answer is not that easy. All four of the twins looked good. All four of the twins, at 10 years out, looked better than they did pre-operatively. So, great surgeons can probably get great results, even if they use somewhat different operative techniques to achieve that result.

Studying the pictures, however, my personal preference was for the results by Dr. Owsley and Dr. Baker. To my eye, these looked the most natural, and the most aesthetically pleasing. This did my heart good – as I use Dr. Owsley’s technique almost exclusively for major facelifts. (Disclosure: I did my facelift Fellowship with Dr. Owsley, learning the technique from him personally, over the course of a year.)

Of interest to me was that the Owsley technique gave a nice result in the neck, without having to open the neck surgically using a platysmaplasty. Also, both Dr. Baker’s and Dr. Owsley’s methods gave excellent correction of jowls and lower facial laxity, and I felt that these methods “aged” better than the other two methods.

Of course, this is a comparison of only 4 patients, not a large, randomized prospective study…nevertheless, it’s fascinating stuff for those of us interested in facelifts!

Plastic Surgery In Florida