Everyone is familiar with “Crazy Glue”. Strong enough to hold a man suspended in mid-air, right? Well, since the 1970’s, people have been tinkering with the formula for medical purposes. These days, we’ve got some decent second generation tissue adhesives, but they’re not perfect. Typically, the glued closure isn’t nearly as strong as a sutured skin closure, so it’s more prone to pop open. And that’s not a good thing.

Enter “Prineo”, from Ethicon. Introduced in Europe a few years ago, it combines a high-tech tape dispenser and a cousin of Crazy-Glue. I saw it demonstrated at the ASPS meeting, and compared to current tissue glues, the new combination system is three times stronger than glue alone. With Prineo, the wound strength is about the same as a standard suture closure.

Here’s how it works: the surgeon sutures the deep layers of the incision, as usual. Next, the tape-like mesh strip is applied over the incision. The mesh contains activating agents for the glue. Once everything is nicely lined up, the glue is painted over the mesh tape, and it sets (polymerizes) within about 30 seconds. This is a bit like a high-tech version of wall patching, with mesh covered by plaster!

Prineo makes a water-tight and reasonably strong closure. Patients can shower immediately postoperatively. The glue peels off easily in about 3 weeks. Reportedly, the cosmetic result is just as good as a subcuticular sutured closure – the plastic surgeon’s usual closure – but we’ll have to see about that! More patient information can be found here.

FDA approval is expected shortly.

Impression: I think this new product could be quite useful for our body-lift patients, especially those with thin skin following massive weight loss. Having additional wound closure strength together with a waterproof closure could be quite helpful for brachioplasties, thighlifts, lower body lifts and such.

One drawback: maybe not so good for hairy areas when it comes time for tape removal. Ouch!

Wanting an attractive tummy is a popular request at our office. But many people are unsure about the differences between tummy tuck and liposuction. The two operations are quite different. Let me explain…

To start, we have to evaluate four different layers of the abdomen, and how they each contribute to the appearance of your abdomen. These are:
– the skin,
– the thickness and distribution of the subcutaneous fat,
– the abdominal wall,
– internal (“visceral” ) fat.

Then, we recommend the most appropriate surgical option.

Liposuction, for example, works very well to reduce the thickness of subcutaneous fat. And that’s about it, in our 4 layer model. Liposuction is powerless to fix muscle wall problems, to treat visceral fat, or tighten skin. So – liposuction is the wrong tool to use if we find that the patient has any of these three issues.

A tummy tuck, works well to tighten loose abdominal skin. At the same time, muscle tightening is commonly done to repair “rectus diastasis”, separation of the abdominal wall muscles. But the tummy tuck is powerless to treat internal (visceral) fat.

Visceral fat – that stubborn internal fat that gives us the “apple” or “beer-belly” shape – is the bad stuff. It’s linked to diabetes, high blood pressure, heart disease and strokes. We can’t get rid of it surgically. The only existing treatment is the hard work of low-fat diet and exercise. Once that internal fat is reduced in volume, then we can usually fix the rest. So, for some patients, the first step is getting their lifestyle under control, and getting down to a healthier weight.

How can you tell what part is subcutaneous fat and what part is internal fat? Here’s an easy method: lie down on your bed on your back, and lift your head off the bed, as though your were about to start a sit-up. This tightens the abdomen. Now grab the tummy fat while keeping the muscles activated. You are now feeling your subcutaneous fat thickness. Anything else – unless you have a hernia – is behind the muscle wall, or internal.

One of the most interesting presentations at the recent ASAPS meeting was the long-awaited results of the lipodissolve / mesotherapy study. Dr. V. Leroy Young, who is an extremely careful and thoughtful researcher, presented the findings.

The study used volunteers with a BMI < 30 and without significant skin laxity, who had a series of injections into their abdomen in an attempt to reduce their subcutaneous fat deposits. There was no dieting, no other drugs, lasers or surgery used. The typical grid pattern of injections was used to one-half of the abdomen, with a pre-mixed combination of mesotherapy agents (PPC/DC). The patient had a series of up to four treatments into the same area, at intervals of 8 weeks. This method was chosen to mimic what is done at many mesotherapy clinics. Careful monitoring was done with a multitude of measurements, photos, lab tests, and CT scans – before, during and after the series of injections. By only treating one-half of the abdomen, each patient served as their own control.

There were no significant changes in BMI or skin-fold thickness, and no blood test changes as a result of the treatments.

In reviewing the photos, the before and after “result” photos looked very similar to me. Not much of a change. If there were changes in body shape, I thought that they looked pretty subtle. If I were the patient, I would be pretty disappointed in these results!

There were a couple of CT scans where I could really see a difference in thickness of the fat layer – so something was happening, at least in some patients, some of the time. According to Dr. Young’s numbers, there was an average reduction of 7% in the subcutaneous fat thickness.

There were no major adverse effects reported in the mesotherapy study group, but patients’ post-op complaints included pain, swelling and nodule formation. Despite that, most of the patients wanted to go ahead and treat the opposite side!

Bottom line: It’s good to finally see this kind of non-biased, carefully controlled research being done. Personally, I was not impressed with the changes, but it might have some application for small areas where a little further refinement of a result might be desired following real liposuction. Too early to tell on that idea, though.

When the final report is issued in the Aesthetic Surgery Journal, I will be able to comment on it in more detail.


As loyal blog readers know, capsular contracture is arguably the most frustrating complication of breast implants, whether they are used for reconstruction or for cosmetic purposes. For years, no one has been particularly sure on why capsules occur, despite all the efforts of the physician and the patient to the contrary.

About a year ago, I wrote a blog entry discussing the theory of biofilms as a cause of the contracture. Biofilms, just to review, are what happens when free-floating bacteria settle on a surface, and set up a colony. The cover themselves with a protective slime layer, and emit certain chemicals to trick the body’s immune system, so they can exist “under the radar”. Biofilms can form on any implant, whether it’s a breast implant, an orthopedic implant, dentures, or injectable fillers.

During the past year, more and more evidence definitively linking biofilms and capsular contracture has been appearing. At ASAPS 2010, we had an update on this. For example, biofilms can be found in the majority of patients with capsular contracture, and are absent in the majority of patients who have no capsule problems. Usually, the bacteria involved is Staph. epidermidis, which lives on the skin normally, and usually doesn’t cause any problems. It also lives within normal breast tissue too, due to the duct connections between skin, nipple and breast gland.

The main problem is: biofilms are notoriously hard to eliminate. Giving doses of antibiotics only temporarily knocks the biofilm down, but it bounces back. Low dose antibiotics have, in some studies, seemed to stimulate the growth of the biofilm. Antibiotic-impregnated implants also only seem to have a temporary effect. These obvious methods have been tried – without success.

It turns out, understanding how biofilms work is fairly complicated. The bacteria actually communicate with one another, using certain signalling molecules. These molecules tell the bacteria when to stick to a surface, and when to form a colony, and so forth. Figuring out how to manipulate these signals is an ongoing area of research. If we could come up with a treatment that blocked these signals, we could probably beat the biofilm problem.

Until that day comes, if we assume that capsules are related to a biofilm layer on the implant which is nearly impossible to remove, it would make sense to consider the following steps at surgery when capsules are involved:
– remove as much of the capsule as practically possible, without causing damage to the surrounding tissue. In other words, capsulectomy (removal) would theoretically be preferred over capsulotomy (releasing cuts) or “neo-pectoral pocket” techniques;
– switch to a brand-new, and thus, biofim free, implant, even if the old implant looks OK;
– use techniques to minimize the possibility of bacterial contamination of the implant, such as opening the implant at the last possible moment, washing it and the pocket with an antibacterial solution, and considering devices like the Keller funnel.

The problem is – there is no science to tell us how much improvement any of these techniques will give a patient, in terms of reducing the rate of recurrent encapsulation. In particular, it would be helpful to know exactly how much using a new implant would help, compared to keeping the old one. Then the patient could decide on the cost-benefit ratio.

Hopefully, those studies will be here soon.

I just returned from the Aesthetic Society’s annual meeting, held just outside Washington, D.C. As usual, ASAPS put on another top quality, well-organized session, with a wide selection of first-rate surgeons from around the world. The next series of blog posts will feature new stories from the meeting.Up first: The Disappointment of Laser Liposuction.

Despite the marketing hype by the laser manufacturers, surgeons are now coming forward saying that they’re just not seeing the hoped-for improvement in results with laser liposuction, compared to standard liposuction methods. The excitement phase, seen when any new technology comes along, is probably over – to be replaced by a more honest, pragmatic assessment phase.

Dr. Jeff Kenkel, laser guru from UT Southwestern, probably said it best with a very honest assessment, “I really wanted to believe in the lasers, and I kept on trying them…”, but then he showed us his clinical results, which showed very little, if any, skin tightening. He admitted there wasn’t a single surgical result obtained with the laser that he couldn’t have been obtained with standard liposuction.

So far, there’s very little good science at this point in 2010 to back up the claims that the manufacturers were making in 2007. That’s not to say that laser lipo is without some merit – it’s just not the magic wand that many promoters have claimed it is. Research is still ongoing, and surgeons like Dr. Barry diBernardino are working hard to present scientifically valid data, not just opinion and “hand-waving”, like we’ve seen in the past.

Many surgeons in the audience felt like the manufacturers really need to show more solid scientific research, before making sales claims. Others of us felt it was really up to us not be conned by preliminary results and sub-standard studies, and to demand better from the manufacturers and the news media.

Of interest, the best lipo results I saw at the whole meeting were done by Dr. Simeon Wall, Jr., of Louisiana. His secret: a three-step liposuction method done with… power-assisted liposuction. No laser, no magic gadget – just a great technique with the tools we already have.

Once again, it’s the carpenter, not the hammer used.

Yes, readers – it’s that time of year again, when the best aesthetic plastic surgeons in the world congregate for their annual meeting.ASAPS 2010 will be held in Washington, D.C., starting in about a week. The latest and greatest, what’s hot and what’s not, and what actually works in cosmetic plastic surgery will be up for discussion….just the sort of stuff we love here at PSB: the plastic surgery blog!

I’ll be attending, listening, learning and questioning. When I get back, I’ll have a full report for everyone….stay tuned.

More and more, I see ads by non-plastic surgeons touting the alleged advantages of having major elective procedures, such as a tummy tuck or a breast augmentation, done “awake” – under local anesthesia. Invariably, these ads tout “avoid risky general anesthesia”, or “quick recovery”.

While liposuction under tumescent (local) anesthesia is an accepted and validated technique, performing breast augmentation or tummy tucks while awake is very controversial, to say the least. The New York Times recently did an investigation on this issue – their article is here (link)

Typically, these procedures are heavily advertised by cosmetic surgeons who are not board-certified in plastic surgery, and who do not have hospital privileges to work in the operating room. Their offices are usually not accredited, inspected surgical facilities. And they don’t typically have an anesthesiologist monitoring the patient.

Really, I feel that the “local anesthesia” angle is a bit of a dodge. It’s a clever bit of marketing spin. The reason most of these “wanna-be’s” promote this is because it’s their only option for anesthesia….they usually can’t get the hospital privileges or work in accredited surgery centers, due to lack of credentials.

There are also real disadvantages to the “local only” technique:
– It can be hard to numb large areas completely, even with the tumescent technique. Remember, just like when you visit the dentist, it can take a few painful shots before the injected area is numb.
– If the local isn’t working 100%, the patients may be fully aware and in pain, as the procedure goes on. I wouldn’t wish that on my worst enemy, thank you.
– You can’t get satisfactory muscle relaxation with just local anesthesia, either – which is important for procedures like tummy tucks, or sub-pectoral breast augmentation.
– it isn’t good for patients who are nervous, or who are resistant to lidocaine.
– lidocaine, the most commonly used numbing agent, isn’t risk free. Toxic doses can occur, resulting in seizures and cardiac arrhythmias.

If you want a rapid recovery from anesthesia, use an expert anesthesiologist, who can monitor the patient, and give them exactly the right doses of medication, keeping them comfortable, but not over-sedated.

Modern anesthesia, administered by an anesthesiologist in an accredited facility, is actually very safe. The risk of something bad happening under anesthesia is less than 1 in 57,000, according to recent studies. Essentially, you are far safer under anesthesia than you are driving your car to work every day.

As for the claims of “quicker recovery”, the recovery from the surgery depends more on the nature of the surgery, on delicate handling of the tissues by the surgeon, good hemostasis, and avoidance of tension on the tissues, all of which are skills that are stressed in Plastic Surgery school.

If I were to have a surgery done, I don’t want to feel it, see it, or smell it, thank you very much. Wake me up when it’s all over. Most of my patients feel the very same way.

Just this week, the American Society for Aesthetic Plasic Surgery (ASAPS) put on an educational webinar for Plastic Surgeons, talking about various recent advances in liposuction. A variety of devices, including Power-assisted Liposuction, VASER, and SmartLipo and the related laser-assisted liposuction devices were reviewed and discussed by the experts.

All of these were compared against the traditional “gold standard” liposuction method of tumescent liposuction, which has been proven to be safe and effective in many published studies. (This is where a thin tube, called a cannula, is hooked to a vacuum, and is used to suction out fat that has been previously injected with a good volume of medication-containing fluid.)

Here are the results:

Power-assisted Liposuction (PAL) got the “thumbs-up” from the panel, as good scientific trials showed that it was as effective as tumescent liposuction, and less fatiguing for the surgeon.

VASER, the latest form of ultrasonic liposuction, was also well received. The panelists liked it for secondary liposuction (i.e. touch-ups) and areas of the body that are fibrous. Some surgeons used it as their primary liposuction tool. Good scientific data was presented to show that this is effective, and safe, as long as the ultrasonic energy applied is not excessive.

Laser-assisted liposuction, such as SmartLipo or CoolLipo, received a veritable beating during the discussions by the experts. Marketing claims by the manufacturers, such as “less invasive”, “safer”, “more skin tightening”, “quicker recovery” and “better results” were each individually addressed and debunked, until not a single one of these claims was left standing. (Cue sound effects: Wham! Biff! Pow!!) Higher laser power machines actually increased the percentages of patients with complications from skin burns.

Essentially, we learned that there was no good scientific proof for any of the laser lipo claims. While these laser lipo machines do remove fat, here’s the key point – they haven’t been shown to do it any better than the other liposuction devices we already have. And there’s been little to no convincing evidence of significant skin tightening in any reputable journal in a double-blinded comparison.

The more honest surgeons in the panel agreed: you can get the same results with any of the current technologies, without spending big bucks for the laser system.

In other words – It’s not the hammer, it’s the carpenter using it.

A skilled, experienced surgeon will get good liposuction results by using good patient selection and appropriate technique. Other than the questionable marketing to technology-obsessed patients who demand the “latest”, there appears to be no additional merit to the laser liposuction methods.

I realize that it may seem hard to believe for those that like to think that the latest laser gadget must be the best. It’s a bit of the old story of the “Emperor’s New Clothes”. Laser liposuction, no matter what smart name you call it, has not been proven to be better than standard liposuction in any controlled scientific trials after several years on the market….and if it were really as marvellous as everyone claimed, we would have had plenty of scientific proof by now.

You know that old saying, about how a young man should look at his prospective mother-in-law, to see how his wife-to-be might look in the future? Turns out, there’s some scientific validity to it….but only if the mother and daughter have similar appearances to start with.

A recent study from Loma Linda University Medical Center found that mothers and daughters who have similar facial appearances age in similar patterns. The team used 3-D cameras and computer modeling to examine the faces of 40 mother-daughter pairs. They found that the signs of aging, particularly volume loss in the lower eyelid, are nearly identical for both moms and daughters. Lookalike mothers and daughters, they discovered, share the way their skin sags as it ages.

The study’s authors feel that these similarities could help guide a plastic surgeon, by offering a reasonably accurate “preview” of what may happen to the daughter’s appearance, and could be particularly helpful for women who are between their mid-30’s and 50, who are considering non-invasive treatments like Botox and fillers.

So – how can you keep yourself looking young for as long as possible? Eat healthy, protect yourself from the sun, and don’t smoke.

Nice summary of 2009 plastic surgery trends in the Wall Street Journal, showing the effect of hard economic times on elective plastic surgery volume.

I’ve reproduced it, below. I’ve added some editorial comments in parentheses.

In addition, you can see the latest ASAPS statistics on plastic surgery, by clicking the link here.


By ANJALI ATHAVALEY, Wall Street Journal

The number of cosmetic-surgery procedures in the U.S. sagged for the second year in a row in 2009, according to an annual survey released Tuesday by a plastic surgeons’ association.

There were 10 million surgical and nonsurgical procedures last year, down 2% from 2008, according to a survey of 928 board-certified physicians by the American Society for Aesthetic Plastic Surgery, a Garden Grove, Calif., group of plastic surgeons specializing in cosmetic surgery. (ASAPS is the largest, most important group of cosmetically-oriented plastic surgeons.)

Driving the decline was a 17% drop in surgical procedures, to 1.5 million surgeries. “People just couldn’t go for the big items,” said Renato Saltz, the association’s president.

Tummy tucks, rhinosplasty and other surgical procedures can cost thousands of dollars more than nonsurgical measures, and they require a longer recovery. (But of course, the surgeries do much more than any non-surgical alternative.)

Indeed, fear of job loss is the main reason people are putting off their surgeries, says Phil Haeck, president-elect of the American Society of Plastic Surgeons, a separate group that has yet to release its annual survey. Dr. Haeck, a plastic surgeon in Seattle, said that marks a shift from last year when consumers cited cost as a primary hurdle. This year, “job priority is number one, cosmetic surgery is number two,” he said.

Breast augmentation beat out liposuction as the most popular surgical procedure for the second year in a row. Dr. Saltz attributes renewed popularity of breast augmentation to the 2006 Food and Drug Administration decision to lift the ban on cosmetic use of silicone breast implants. Breast augmentations numbered 311,957 last year, down 12% from 2008; liposuctions numbered 283,735, down 17%.

Nonsurgical procedures, such as injections of Botox or hyaluronic acid to fill facial wrinkles, were flat, inching up 0.6% to 8.5 million.

Two surgeries are surging in popularity. Buttock lifts, which involve reshaping of the bottom, increased 25% to 3,024 procedures, and buttock augmentations increased 37%, to 4,996. Increasingly, people want to reshape their rears after losing weight, Dr. Saltz said.

The procedures, costing from $4,000 to $5,000, are fairly new, with both benefiting from recent technique improvements, he added. As the economy recovers, more baby boomers are expected to seek procedures, and more physicians will likely offer nonsurgical options. Surgical procedures have increased by 50% since 1997, while non-surgical procedures grew 231%. Places like health clubs and spas are already offering minimally invasive procedures. (Not recommended!) Cosmetic-surgery associations recommend that consumers seek out procedures that are conducted under the supervision of a board-certified physician.

They should also do research before going overseas for cheaper rates for surgical procedures, which physicians say is a growing trend. “Right now, there is not an association that verifies that the physician is appropriately trained to do what they are doing,” said Dr. Haeck. “Very few of the countries where these are being offered have anything that approximates the rigorous boards in the United States.” (Canada is one exception – their training standards are equivalent to the U.S.)

Plastic Surgery In Florida