How big is too big? Breast implants and size

I was browsing some of the breast-implant related sites Implants411, implantinfo,
Yes, They're fake!, etc... this past weekend and had a few thoughts.

What's being played out to me on many of these bulletin boards is some poor educational efforts by the surgeons these women are consulting with. I'm really taken aback by the size and location (subglandular position) that many of the participants in those forums are reporting that they've had done or been recomended to have done. What I don't think is being adequately represented to these women are the long-term consequences of large implants on their tissue. 5' 6" 120 lb women do NOT need 500cc implants and that just appears to be too common a reported scenario.

Predictably what we (Plastic Surgeons) are going to be creating is an attenuated skin envelope with potentially irreversible or difficult to correct deformities. This is the nexus of patient's obsession with size colliding with a cosmetic surgeons desire not to alienate a potential client. The debate about which master we serve with breast augmentaion- the patient's desire or the patient's best interest is a debate that has generated a lot of controversy. There was a particular nasty spat in the letters column of
Plastic & Reconstructive Surgery (our flagship journal)last year on this topic with alternating charges of wrecklessness versus (allegedly) paternalistic attitudes towards patients.

Having done a fellowship in breast surgery heavy in revisional surgeries, I'm more and more convinced that we (as a specialty) deserve an F (or a least a DD :) )on our communications in this area.

PS News on face transplant

Ok... Last words on the face transplant.

I read some interesting information in the February 2006 "Plastic Surgery News" (a professional newletter from the American Society of Plastic Surgery) today re. this that I had not seen reported elsewhere.

This is quoting Dr. Bob Walton, a distinguished microsurgeon and former chief of Plastic Surgery at the University of Chicago. He says "After they did the transplant, the face looked wonderful... But over the past two months it's slowly started to sag due to loss of muscle tone - it looks paralyzed." He ponders whether an inanimate face with constant drooling as the final result will have been worth the morbidity of the surgery and the immunosuppressive regimine. He's 100% on target.

Also discussed are what are some very signifigant acute rejections by her body of the transplanted soft tissue requiring multiple large bolus doses of steroids. This does not bode well for long term graft survival from what I remember about transplant surgery

The new post-bariatric world

A whole new area of Plastic Surgery has exploded within the last 5-7 years, that being the treatment of the massive weight loss (MWL)patient after the various Bariatric (weight-loss)surgeries being performed. These patients present a whole range of new problems that were poorly addressed by many standard techniques in body contouring surgery.

The attached picture is from Dr. Al Aly's book that focuses on the treatment of their unique deformities. What it so illustrative by this picture is the sheer variety of body shapes that people present with after MWL. They came in all sizes from the still obese to those resembling a shar-pei dog with loose skin hanging everywhere off an emaciated frame. Plastic Surgery meetings have now even been developed that focus only on educational efforts with these patients.

The scale of some of these surgeries can be staggering (not to mention the cost) and can take many hours and multiple stages. These patients also are at very high risk for complications, including pulmonary emboli and frustratingly persistent fluid collections (seromas)requiring multiple treatments.

It was interesting during my training, that I was in the middle of my Surgery residency the development of the modern techniques of both the weight loss operations (the Laparoscopic gastric bypass and the Lap-Band procedures) followed by the MWL explosion during my Plastic Surgery training. This has made the transition to working on these patients much less intimidating to me then it is to many surgeons who trained in years past.

Right now I'm seeing 5-6 new candidates for post-bariatric treatment weekly which has been enjoyable. What is getting more difficult is the limitations of what I'm able to offer these patients. Insurance reimbursement for these cases does not reflect the time, effort, and risk assumed to do these MWL procedures. In addition, many insurers are now refusing to pay for the body rehabilitation at all. This is fine, but a lot of these patients do not have the means to finance the many thousands of dollars this costs out of pocket.

Other blogs of interest

I'd just like to give a shout out to another Plastic Surgery blog that got me interested in doing this blogging thing. Dr. John Disaia's Truth in Cosmetic Surgery Blog. This was the first site I saw on Plastic Surgery that actually had content on it that I wanted to read.

Another superior blog on General Surgery is "Bard Parker's"Cut To Cure. A great view from the trenches written under a pseudonym. Good stuff!

There are some really bad Surgery blogs that are essentially newsletters for the practice. THIS WILL NEVER BECOME ONE OF THOSE . Amen!

Rob Oliver

Living in the fishbowl

I've got to confess a guilty pleasure........

Celebrity Plastic Surgery sites. There's a number of these around which take great joy in pointing out the various procedures that certain celebs may (or may not) have had done. The picture to the right is of notorious socialite, Jocelyn Wildenstein, whom one might charitably describe as having been over-operated on.

The grand-daddy of these sites Awful Plastic Surgery has the best content I think.

What amazes me is some of the really bad work some of them appeared to have despite the fact that many of them could afford the premier surgeons in the world to do their surgery.

A few rules that should be mentioned that you see violated in these photos over and over:

1. Don't put over-sized breast implants in, especially over the top of the pectoralis muscle. You end up with aged looking breasts that are wrinkled, rippled, and bottomed out.When you put larger implants in, you ensure a short-term "lease" of your breast shape.

Premier Dallas breast surgeon,John Tebbetts has been the most passionate patient advocate on this.

2. BEWARE silicone cheek implants. There is no greater freak-inducing look then bad implants

3. Volume replacement with fillers may be preferable to many traditional face-life & eyelid surgeries to avoid the tight, "wind-swept" look of face-lifts and the "corpse-like" effect of defatting the orbit with aggressive fat-removal during blepharoplasties.