It seems that, every few months, there’s a new variation on our old friend, liposuction. This time, the latest phrase is “tickle liposuction”. (ed: I don’t know who comes up with these marketing terms, but really – tickle??)It’s just a variation on power-assisted liposuction (“PAL”), which has been around for years, and works great. Instead of the cannula moving back and forth by a few millimetters, as it does in PAL, in “tickle” liposuction, the cannula rotates through a small conical arc of motion, much like a spinning top that is slightly off balance.Everything else about the liposuction part is exactly the same as PAL.

  • Do I honestly expect “tickle lipo” to be any better than what we already have? No.
  • Is it FDA approved? Yes.
  • Is it safer? Unproven.
  • Is there less risk, faster recovery, and less bruising? Compared to what? Unproven
  • Does it tighten and smooth the skin? Doubtful
  • Does it give unbeatable results? Depends on the surgeon.

Remember: it’s not the gadget that makes for excellence in liposuction, it’s the surgeon, and their experience and care in performing the liposuction surgery.

If you’re like most people, you’ve never heard of ALCL. Well, you will now, because the FDA has just issued a bulletin, drawing attention to this exceptionally rare disease. ALCL is a subtype of non-Hodgkin’s lymphoma. ALCL is NOT breast cancer, but an entirely different disease. It can affect lymph nodes, skin or breast tissue.

About 3 people per 100 million will be diagnosed per year with ALCL of the breast, whether they have breast implants or not. It’s really rare. Most plastic surgeons will never see a case of ALCL during their lifetimes. You’re more likely to be hit by lightning and win a major lottery on the same day.

Why are we talking about this rare disease? Because there have been some early reports of ALCL occurring in women with breast implants, so the FDA is investigating whether there is any link between the two. There have been between 34 and 60 cases reported worldwide in women that also have breast implants. The FDA isn’t saying there is a definite link for sure, just that there might be a “possible association”.

So far, we don’t know that much from a tested, scientific point of view. Some of the reported cases happened in women after breast reconstruction, some after cosmetic use. Some have happened with saline implants, some with silicone.

Scientists aren’t even sure whether these cases really had “classic” ALCL, or whether it represents something new that happens to look like ALCL. Fortunately, the disease seems to respond well to treatment.

Phillip Haeck, MD, President of the American Society of Plastic Surgeons (ASPS) said “ASPS shares the FDA’s commitment to patient safety, but we also want to make certain this information does not raise false alarms with our patients. We’ve been down this path before. For nearly 20 years American women were denied access to their choice of breast implants because of false claims and unfounded science. We are determined this shouldn’t happen again.”

Women that have implants certainly don’t need to panic. There’s no need to have your implants removed.

The FDA is setting up a central registry to look at the reports in more detail, which is a good thing. I’ll keep my patients informed, as we learn more.

My advice: do what we’ve always advised our patients. Do your own breast self-examinations. Get mammograms and ultrasounds of the breast, following the normal schedule. If you notice something new, like swelling or a lump in the breast, let a doctor check you over. But otherwise, there’s no need to panic. The FDA’s actions are out of an extreme abundance of caution.

The pain-reliever acetaminophen (also known as paracetamol or APAP) is one of the best-selling over the-counter medications. It is sold under many brand names, including Tylenol, and is an ingredient in nearly 200 medications and preparations. It is often combined in prescription pain medications with other ingredients, usually opioids such as codeine (Tylenol with Codeine), oxycodone (Percocet) and hydrocodone (Vicodin).

The recommended daily limit for acetaminophen is 4,000 mg per day.Yesterday, after years of deliberation, the FDA announced a new rule, limiting manufacturers of prescription combination products that contain acetaminophen to no more than 325 milligrams (mg) in each tablet or capsule. They feel this rule should help reduce the number of accidental acetaminophen overdoses. Currently, many popular products have 500 or 650 mg of acetaminophen in each tablet. People who take these extra-strength medications every four hours can easily find themselves taking more than the recommended daily total dose….

When taken in high doses, acetaminophen can actually cause serious liver damage – and even acute liver failure and death. In fact, acetaminophen toxicity is one of the leading causes of liver failure in the United States, accounting for more than 56,000 emergency room visits, 2,600 hospitalizations and an estimated 450 deaths per year. Often the overdose happens inadvertently, when a patient takes one acetaminophen-based medicine for back pain, another for migraines, and perhaps a third for cough and cold symptoms.

Most people are only at risk for liver toxicity if they take significantly more than the normal recommended amount of acetaminophen. Most cases of liver damage occur in people who have taken at least 10-15 grams — more than twice the recommended dose. However, a study by the FDA showed that about 20% of people with acetaminophen-related liver toxicity had taken less than the recommended daily amount. These are usually people who combine acetaminophen with alcohol, or who have pre-existing liver disease.

The elimination of higher-dose prescription combination acetaminophen products will be phased in over three years and should not create a shortage of pain medication.

The following tips can help prevent acetaminophen related liver toxicity:
• Do not take more than the recommended dose of 4 grams within a 24-hour period (for example, 12 regular strength or 8 extra strength Tylenol tablets)
• Do not take the full day’s dose at one time; space it out over the course of the day
• Do not take acetaminophen for more than 10 days in a row.
• Avoid drinking alcohol when taking acetaminophen.
• People who do consume 2-3 alcoholic drinks per day should not take more than half the usual recommended dose of acetaminophen (2 grams within 24 hours).
• People with advanced liver fibrosis, cirrhosis, or Hepatitis B or C should speak with their specialist before taking acetaminophen.
• Check the labels of all medications; small doses of acetaminophen in combination remedies can add up to big trouble.

We’ll be reviewing our post-operative pain medications to make sure our patients don’t get more than the recommended dose

As reported here on the BBC Health website, a new U.S. NCI-funded study looks at how fast the body starts making carcinogenic compounds after inhaling cigarette smoke.

The report, published in Chemical Research in Toxicology, shows that cancer-causing chemicals appear in the bloodstream within 15 to 30 minutes after smoking.

Small bit of biochemistry here: Polycyclic aromatic hydrocarbons (PAH) are some of chemicals that cause lung cancer in smokers. PAH’s require activation by the body to exert their carcinogenic effects. One activation pathway is the conversion to a nasty compound called a “diol epoxide”, which is what then causes DNA mutations and starts the cancer formation.

So, the researchers let 12 subjects light up a cigarette laced with a stable PAH (called phenanthrene), and checked their blood to see when the converted diol epoxide would appear. Bad news: the cancerous compound was seen right away, at high doses, at the very first blood draw, 15-30 minutes after smoking.

Obviously, this should be pretty chilling news for smokers, and even more incentive to quit. Damage from smoking starts immediately.

As we’ve discussed before, capsular contracture around a breast implant is the #1 most frustrating problem of breast augmentation surgery. Despite a “textbook” surgical procedure and a perfect patient, hardness around the breast implants still can sometimes occur. Until recently though, we’ve always thought that the choice of the incision doesn’t affect the results of the breast augmentation. Turns out that may not be the case.In this month’s issue of Plastic and Reconstructive Surgery Journal, a review article on breast augmentation discusses a recent clinical study which showed capsular contracture happens much more frequently with a peri-areolar (nipple) incision, and less often with an infra-mammary (crease) incision.

In the study, the incidence of capsular contracture was just 0.59% in the inframammary incision group,but a whopping 9.5% in the peri-areolar incision group. Periareolar mastopexies performed at the same time as breast augmentation also showed this elevated contracture number, but were not significantly different than peri-areolar breast augmentations alone. These findings do correspond with my own observations, but I am amazed at the huge percentage difference between the two groups, which is much more than I expected.

Why does this happen with the nipple approach? Probably due to biofilm. Cutting through the breast will inevitably open the micro-ducts within the breast tissue, which are colonized with skin bacteria.

Does this mean we should completely abandon the periareolar incision? No, but it’s certainly a major drawback to this approach, even though, cosmetically speaking, the nipple incision may look and hide better than a infra-mammary (crease) incision, when the color of the scar blends in with the color of the nipple skin. The question now becomes: is the improved scar worth the gamble of developing a encapsulated breast? I suspect that, given the choice, most patients will choose the approach that avoids capsular contracture.

When I speak with patients in future, I’ll certainly tell them about this study, and that a periareolar incision breast augmentation is 15 times more likely to develop capsular contracture.

The US Food and Drug Administration (FDA) has asked that propoxyphene, (brand names Darvon and Darvocet) be removed from the US market. The decision will also affect generic manufacturers and the makers of propoxyphene-containing products.

At a press conference last week, Dr Gerald Dal Pan, director of the FDA’s Office of Surveillance and Epidemiology, said “For the first time, we now have data showing that the standard therapeutic dose of propoxyphene can be harmful to the heart.” Side effects of cardiac arrhythmias and other electrical disturbances were noted.

The FDA is advising healthcare professionals to stop prescribing propoxyphene. Patients who are currently taking the drug should not abruptly halt their medication but should contact their physician as soon as possible to discuss switching to another pain-management therapy.

“Long-time users of the drug need to know that these changes to the heart’s electrical activity are not cumulative,” Dal Pan added. “Once patients stop taking propoxyphene, the risk will go away.”

Propoxyphene is an opioid typically used to treat mild to moderate pain. It was first approved by the FDA in 1957. It is sold by prescription under various names alone or in combination with acetaminophen.

A phased withdrawal of propoxyphene is already under way in Europe. The European Medicines Agency made that decision in June 2009.

In journalism, reporters are always excited when they “scoop” the competition – and report on a story before the other guys. So, I’m pleased to report a bit of a “scoop” here. Last May, we discussed the thread lift technique (link here) and commented on how it didn’t work for very long, and how the results were subtle and short-term at best.

Just this week, in the highly respected Yearbook of Plastic and Aesthetic Surgery, I see two reports on threadlifts. The authors note that the results are dismal:

“rates of revision surgery…are high after threadlift”

“time to revisional surgery is short”

“results achieved by threadlift are subtle and short-lived”

“threadlift is not a minimally invasive replacement for rhytidectomy (facelift)”

“the threadlift provides only limited short-term improvement”

Summary: There are surgeons locally that recommend and use threadlifts. Just say no – don’t have threadlift procedures done. The experts feel they are a waste of time and money, as they are quite ineffective and don’t last.


Sheyla Hershey, the Brazilian-born Texan model/actress/singer who became known mostly for her quest for ever-larger breast implants, developed complications after her latest set of M-cup implants, which were implanted in South America after U.S. surgeons refused, became infected and began to extrude through her thinned-out skin, despite IV antibiotics.

The full story is here, in the Orange County Register.

Ms. Hershey had reportedly had approximately 8 to 10 previous breast surgeries to reach that size, and had been awarded a citation in the Brazilian edition of the Guinness Book of World Records for having the “largest breast implants in Brazil”.

Take home lessons: 1) really big breast implants are associated with increased risks, including tissue thinning, pocket stretching, ptosis (droop), wound healing problems, and a much higher rate of secondary surgeries. Even when they are not as nearly as large as Ms. Hershey’s.

2) It’s unwise to push tissue way past where it was meant to go.

3) Listen to your surgeon. If he/she tells you that it would be unwise or not in your long-term best interest to do an operation, don’t run down the street (or go to South America) just to find a surgeon that will do what you want. Maybe it’s time to think twice.

Remember, back in November, we brought you the story of a Texas lady who was illegally selling fake Botox and filler products under the the name “Discount Med-spa”?

Well, it seems that her conviction and sentencing had no effect, as here’s yet another website selling bogus imitation Botox under the name Pretique. (link)

This material is to be avoided.

I have no idea what this product is. And no idea what’s really in it, how it’s manufactured, how potent it is, or any other quality control information. It’s certainly not anything remotely legal, and is in no way associated with any of the authentic manufacturers of botulinum for cosmetic uses, like Allergan. It’s a scam.

Avoid the use of these knock-off products. They could, like the people who used one of the other imitation products, known as “Tri-tox”, put you in the ICU on a ventilator.

And that’s not a good way to spend your summer vacation!

(Thanks to for the heads-up on this.)

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.

Plastic Surgery In Florida