How often do you hear about “no recovery” or “lunchtime” treatments when reading about lasers, peels and other treatments in the media?  Until recently, there was no accepted definition for these terms. What does “minimal recovery” really mean – minimal to whom, the doctor, or to you?

The American Society for Aesthetic Plastic Surgery (ASAPS) has developed a set of standardized definitions that consumers and industry can use, when talking about issues like downtime, bruising, redness, swelling and pain.  We’re trying to encourage the cosmetic laser industry to adopt and use these terms in a consistent and honest way, so that consumers can really fully understand what they’re choosing, and can compare treatments while shopping around.

DEFINITIONS OF TERMS

Downtime –the expected time to return to normal lifestyle

Essentially None: less than 24 hours

Minimal: 24-72 hours

Moderate: 3-7 days

Significant: more than 7 days

 

Bruising – visible on the skin without concealer

Essentially None: no bruising but there may be an immediate change in skin tone

Minimal: less than one week

Moderate: 1-2 weeks

Significant: more than 2 weeks

 

Redness –visible without concealer

Essentially None: returns to normal (pretreatment or improved) in less than 24 hours

Minimal: 1-3 days

Moderate: 4-7 days

Significant: more than 7 days

 

Swelling –obvious swelling

Essentially None: less than 3 days

Minimal: 3-7 days

Moderate: 8-14 days

Significant: > 14 days

 

Pain –significant discomfort associated with the treatment

Essentially None: no anesthesia or medication is needed except over the                                      counter  medication

Minimal: requires pretreatment with oral prescription medication, topical anesthetic agents                or skin cooling and/or post-treatment prescriptions for pain management.

Moderate: same as minimal but with local anesthesia (injections)

Significant: same as minimal but with IV sedation or general anesthesia

On Friday, Sientra announced a new warranty program, which they are calling “C3”.  The program, which begins Novemeber 1, 2013, will apply to first-time breast augmentation patients who choose Sientra-brand textured implants.
In addition to the current implant deflation warranty, the C3 program provides a free replacement implant if the patient requires revisional breast surgery for a Baker Grade III or IV capsular contracture, within the first two years after the original implantation surgery.
No additional registration forms or fees will be required.
Capsular contracture is one of the most frustrating and unpredictable complications after breast implant surgery.  Previous studies have found that it happens more often in the subglandular implant, if a periareolar or trans-axillary approach is used, or if there is bleeding or infection in the breast.  In some studies, smokers have an increased risk.
In the upcoming November issue of Plastic & Reconstructive Surgery, a new study looking at Sientra implants also found a protective effect for their textured breast implants, when compared to the smooth Sientra implants.
Bottom line:  I’m sure that patients who choose Sientra’s gummy bear implants will be pleased to hear about this program, going forward.  It will be interesting to see how the other established manufacturers – Allergan & Mentor – react to this new program.
Benelli Breast Lifts Orlando, Advances in Breast Lift SurgeryMany patients who would like a more uplifted and perky breast shape tell me that they are very worried about a breast lift, due to the surgical scars.  Most women worry that they will need the traditional anchor lift – and that’s not always the case.  Today, I’d like to talk about one type of breast lift, which has a very minimal amount of scars:  the donut lift.  It goes by several names.  You might also hear the terms “Benelli lift” or “circumareolar lift” mentioned by surgeons.
The concept is simple:  limit the scars to just the outside of the areola.  There’s no scar down the front or underneath the breast.  This technique can work nicely for women that have reasonably elastic skin, and only need a small lift, where the nipple position just needs to lift up 1-1.5 inches to look centered properly.  The nipple stays attached, and sensation is preserved.  Only an off-center donut-shaped zone of extra skin is removed. A careful skin closure, with multiple layers of sutures, is then performed.
The Benelli lift works particularly well for women with tuberous breasts or prominent, dome-shaped areolas. (“puffy nipples”)  It is also very effective when combined with a breast implant or with fat grafting to the breast to restore missing breast volume.  There are many examples of this technique in our photo gallery.
Most times, the incision blends in nicely at the edge of the areola, and a nice improvement is obtained.  An internal “purse-string” suture, made of a long-lasting Gortex thread, helps to prevent the new areolar shape from stretching back out, maintaining the lift effect over many years.
If you are thinking about a breast lift, but are worried about the scars, ask Dr. Fiala if this method might work for you.

Today, the FDA announced the approval of the “MemoryShape” breast implant, made by Mentor.  This is the teardrop-shaped implant, filled with the latest generation of form-stable silicone gel.  It’s certainly a home-run for breast reconstruction patients, and may be useful for some breast augmentation patients as well.  Mentor now joins Allergan and Sientra with implants of this type.

Today’s approval was based on six years of safety data. The silicone gel in the MemoryShape Breast Implant contains more cross-linking compared to the silicone gel used in Mentor’s regular silicone gel implant. This gives it a firmer feel, compared to our usual silicone implants, and makes it more leak-resistant.
As usual, the FDA approval came with conditions.  This time, Mentor must continue to monitor the patients from their 2 pre-market studies, conduct a new 10 year study of 2500 women to collect more information on long-term complication rates, and start another 10,000 patient study, looking for rare diseases in women that have implants.The Mentor MemoryShape implant, previously known as the “CPG implant”, will now compete with Allergan’s Style 410 implant, and Sientra’s implants.  All three implants feature a firmer gel, the teardrop shape, and some type of textured “fuzzy” coating, which varies by manufacturer.We’ll see whether these catch on with American consumers.  There are pros and cons to the new designs.  They require a much larger incision, are significantly firmer to the touch, and still require follow-up imaging studies.  They have a drawback that round implants don’t have – which is rotation of the implant, which occurs in about 5% of patients.  Their shape is very conservative – it doesn’t really give any significant fullness in the upper part of the breast, which, in my practice, is one of the most commonly-asked for features women request during their breast surgery consultation.  On the other hand, it does look very natural, and is more leak-resistant in case of a break in the implant’s shell.

BELOTERO BALANCE Dermal Filler before after picturersWhile most people are familiar with Restylane and Juvederm, you might want to get to know the new kid on the block, Belotero Balance.

Just like Juvederm and Restylame, Belotero is an FDA-approved filler that is also made from hyaluronic acid gel.  But it’s manufactured a little differently, and has a smooth and soft consistency.  It’s quite useful for superficial wrinkles, and gives a nice, natural-looking correction.

Other HA fillers, when they are placed too close to the surface of the skin, can have an issue called the “Tyndall effect” – which basically looks like a blue-grey colored bleb caused by the superficial placement of the filler.  This doesn’t happen with Belotero.  So it’s really quite useful in areas where the skin is thin, like near the eyes.  Belotero, however, does not come with added lidocaine, which may be a disadvantage for some patients, making the injections a little less comfortable.

The manufacturer, Merz Pharmaceuticals, claims that Belotero lasts longer than the other fillers, up to 12 months, rather than the usual 6 to 8 month duration for Juvederm.  I haven’t seen a head-to-head comparison study yet, so will have to wait and see on that claim.

For more information of the treatments and procedures offered at this Orlando Plastic Surgery Center & Medical Spa by Plastic Surgeon, Dr. Thomas Fiala, please contact us at (407) 339-3222(407) 339-3222 or visit:

Allure Magazine’s senior editor, Ms. Joan Kron, recently published an article called the “11 most overrated cosmetic surgery procedures”(link), and I thought this was well worth commenting on.  Ms. Kron has received several awards from our plastic surgery societies for journalistic excellence in covering our field – so her articles are always worth a read!

Here are her picks – the cosmetic procedures where the downsides, risks or simply the lack of proven benefit based on scientific data – make the procedure of questionable value.  I’ve added my comments to each one. Drum roll, please…..

1.  Vampire Facelift – There’s no good science to support this treatment as being beneficial.  I don’t perform it, even though Ms. Kardashian and others celebs like it. (link)

2.  Laser Liposuction – There’s no study showing it’s actually better, results-wise, than regular liposuction.  But the trademarked name sure sounds cool, doesn’t it?  It’s certainly not minimally-invasive, as often advertised.  While some surgeons are enthusiastic about it – typically those who have bought the machine and have to make the payments on it – others say it causes more scar tissue, and makes further liposuction more difficult.  I’m in this second group – so I use Power Assisted Liposuction, which has a proven track record.

Recently, Cynosure, the manufacturer of SmartLipo is promoting a modified version of SmartLipo for use in the face called the “lazerlift”.  Don’t do it!  There’s a whole blog post coming on this bad idea!

3.  Stem Cell Facelift – The New York Times just did an article on this (link).  Most doctors that offer a so-called stem cell facelift are really just doing standard-issue fat transfer to the face.  Since 1% of the fat contains stem cells, they use the “stem-cell” buzz word.  Very misleading.

4.  Sculptra and Artefill for the lips – These products are designed for the cheeks and other areas where they can be placed deep in the tissues.  In the lip, they will cause lumps for sure.  And did I mention that these are permanent lumps?

5.  Silicone Cheek Implants – Pretty much made obsolete by our injectable products and fat grafting techniques.

6.  Ulthera – Very subtle ( i.e. hard to see) results, painful to have done.  Current treatment protocol is “under revision” by the company.

7.  Fat Injections To The Breasts – Here’s one topic where I disagree with Ms. Kron.  I think that this really is a useful technique, for both augmentation and reconstructive purposes.  It’s certainly more expensive and more time consuming than a breast implant, and gives a different, more natural looking result than an implant.

8.  Brachioplasty – The issue here is the scar, that typically goes from  armpit to elbow.  This can be a great procedure for massive weight loss patients, especially with our posterior scar technique.  It’s not good, however, for someone who just needs a little improvement of a basically normal arm silhouette.

9.  Buttock Augmentation with Implants –  These are really only used if the patient is not a candidate for fat transfer to the buttock, also called the Brazilian Butt Lift.

10.  Zerona Lipo Laser – Essentially this is like shining a few laser pointers on your skin and expecting there to be fat loss.  I am still surprised that this gadget got FDA approval.

11.  Foot Lifts – My scrub tech, Lindy, says “no go on toe lipo”.  Or cosmetic foot surgery.  I agree!

For more information of the treatments and procedures offered at this Orlando Plastic Surgery Center & Medical Spa by Plastic Surgeon, Dr. Thomas Fiala, please contact us at (407) 339-3222(407) 339-3222 or visit:

Yes, it’s that time of year:  time for the biggest gathering of aesthetic plastic surgeons from around the world, the annual American Society for Aesthetic Plastic Surgery meeting.  This time, it’s back in New York City, at the Convention Center, starting in about 3 weeks.

I’ll be there, listening to the latest on technical improvements and new equipment, participating in several committees and a couple of panels.  This year, for the first time, I am heavily involved in a teaching course which I’m pretty excited about.  It’s called “What Patients Really Want”, and it is all about how to improve the overall patient experience as they go from consult to surgery to post-operative care.  I’ll be joined by ASAPS past-president Dr. Monte Eaves,  Realself.com CEO Tom Seery, and Marie Olesen, plastic surgery consultant par excellence and founder of Real Patient Ratings.  It has the potential to be really good!

As usual, I’ll be reporting from the meeting, and will blog about what works, what new & cool developments I see, as well as the flops, failures, the hype and the spin.  Stay tuned…

If you study a youthful-looking face and compare it to its older counterpart, one of the things you’ll notice is that the younger face has fullness in the cheeks, and the older face doesn’t.  The older face often loses volume – in the temples, in the cheeks, in the lips.  And until recently, plastic surgeons have struggled to reverse these changes.  While we were good at tightening up cheeks and necks with facelifts, replacing lost volume in the face was a different matter entirely

After a number of years of work, I’m pleased to say, the techniques of fat grafting to the face have advanced to the point where many of these problems can be significantly improved in a much more reliable way.  The concept, like many great ideas, is simple:  harvest a little bit of fat from an area of the body where it is unwanted, purify it, and inject it, a droplet or two at a time, precisely where it is needed.  It’s almost like miniature liposuction in reverse.  You can almost think of it a sculptural process.

I’ve been working with fat grafting over the years too – and in the early days, there were frustrating technical problems with the harvest and re-injection portions of the procedures.  These have been largely solved with the inroduction of more refined instrumentation.  Our understanding of how and where to put the fat has also improved.

Now, we’re starting to combine fat grafting with facelifting.  This is a winning combination, as each procedure does different things to restore the look of youth, and they both work together well.  The facelift repositions and tightens the tissues of the cheeks, jawline and neck.  The fat grafting fills in the hollows and plumps up the curves where needed, allowing contouring we never could achieve before, particularly in the midface.

And the recovery from facial fat grafting by itself is much easier than a full facelift.  If you would like to learn more about facial fat grafting, please come and see me for a complementary consultation.

IN THE UPCOMING ISSUE OF PLASTIC AND RECONSTRUCTIVE SURGERY, DR. ROGER KHOURI AND ASSOCIATES GIVE US AN UPDATE ON THEIR EXPERIENCE WITH FAT TRANSFER TO THE BREAST FOR THE PURPOSES OF BREAST AUGMENTATION. THE BOTTOM LINE: AS LONG AS YOU USE THE BRAVA SYSTEM FOR SEVERAL WEEKS BEFOREHAND, FAT TRANSFER WORKS PRETTY WELL.

IN THE STUDY, 81 PATIENTS USED THE BRAVA FOR 4 WEEKS BEFORE SURGERY, THEN HAD THEIR OWN FAT TRANSFERRED WITH LIPOSUCTION HARVESTING TO THE BREAST. THEY THEN WORE THE BRAVA POST-OP FOR AT LEAST A WEEK. AN AVERAGE OF 277 ML PER BREAST WAS USED – WHICH, COMPARED TO TYPICAL BREAST IMPLANTS, IS A PRETTY CONSERVATIVE VOLUME. THE PATIENTS WERE FOLLOWED FOR AN AVERAGE OF 3.7 YEARS POSTOPERATIVELY.
BASED ON MRI DATA, THEY FOUND ABOUT 82% GRAFT SURVIVAL, WHICH WAS MUCH BETTER THAN EARLIER STUDIES IN WHICH THE BRAVA SYSTEM WAS NOT USED, WHERE THE AVERAGE FAT GRAFT SURVIVAL WAS 55%. ALSO, THE BETTER THE PRE-EXPANSION WAS WITH BRAVA PRIOR TO SURGERY, THE BETTER THE RESULTS. THERE WERE NO SUSPICIOUS BREAST MASSES OR NODULES DURING THE FOLLOW-UP PERIOD.
THESE RESULTS ARE PRETTY MUCH THE SAME AS WHAT DRS. KHOURI AND DELVECCHIO PRESENTED AT LAST YEAR’S BREAST SURGERY CONFERENCE IN BOSTON. BUT NOW THE DATA HAS GONE THROUGH THE FORMAL PEER REVIEW PROCESS.
I’M A FAN OF THIS TECHNIQUE. AS A PLASTIC SURGEON, IT’S EXCITING TO BUILD SOMETHING OUT OF NOTHING – OR IN THIS CASE, BUILD A BREAST OUT OF OTHERWISE UNWANTED FAT. PLUS, THE PATIENT GETS THE BENEFIT OF THE CONTOURING FROM THE LIPOSUCTION AT THE FAT DONOR SITE. WE’RE STILL WORKING ON METHODS TO STREAMLINE AND STANDARDIZE THE OPERATION, BUT IT DOES WORK. WEARING THE BRAVA REALLY DOES HELP THE FAT TO SURVIVE, AND OUR EARLY EXPERIENCE WITH THIS METHOD HAS BEEN VERY PROMISING.
BUT WEARING THE BRAVA SYSTEM ISN’T EASY OR COMFORTABLE – IT CERTAINLY DOES REQUIRE A SOLID COMMITMENT FROM THE PATIENT, TO WEAR IT 10 HOURS A DAY, EVERY DAY FOR THE REQUIRED TIME – SO IT’S NOT FOR EVERYBODY. THE SURGERY IS MORE EXPENSIVE THAN AN IMPLANT SURGERY. ALSO, IF YOU WANT MORE THAN A CUP SIZE INCREASE, OR THE HIGH-PROFILE IMPLANT LOOK, IMPLANTS ARE CURRENTLY STILL THE BETTER CHOICE. WITH FAT GRAFTING, HOWEVER, THERE’S NO WORRIES ABOUT IMPLANT DEFLATION OR CAPSULAR CONTRACTURES – AND THAT CAN BE PRETTY APPEALING FOR THE RIGHT PATIENT.

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