Monday, January 26, 2009

How to make breast augmentation less painful - Depobupivicaine

One thing that patients frequently ask about when considering undergoing breast augmentation is how much pain and discomfort they'll experience. I think in general, the pain is directly correlated to the surgical technique.

If you could find a video of breast augmentation circa 1975, you'd see a set of instruments like this used:

Those hockey-stick shaped devices are called "Dingman breast dissectors" (after Dr. Reed Dingman, former chief of plastic surgery at Michigan in the 1960's-70's). Basically, they're a lever to mechanically dissect a pocket to place an breast implant into. Breast augmentation in that era consisted of making an incision, shoving one of these instruments in, tearing a pocket out bluntly, and holding pressure until the patient quit bleeding. Sounds great, huh?

Blood around an implant, as we know, is a potent stimulator of capsular contraction, and techniques like this combined with silicone implants of that era probably precipitated many (with a capital M) cases of hardening breast. There is no way to predictably minimize bleeding with blunt dissection, and it should be largely avoided in breast augmentation except when gently refining a previously dissected pocket.

Believe it or not, there are still some surgeons who use that kind of technique when they place implants thru the armpit (transaxillary approach) and belly button ("TUBA" technique). Evidence based medicine and the refinements in surgical techniques described by surgeons like John Tebbetts, Pat Maxwell, and others have clearly shown us ways to get better results, with less bleeding, less inflammation, and softer breasts over the long term.

The key to safe and excellent plastic surgery is precision and planning. As the apocryphal "7 P's" quote from the British military goes:
"Prior Planning and Preparation Prevents Piss Poor Performance". This is particularly true as it relates to long term outcomes from breast augmentation surgery.


The take home message is that more atraumatic technique produces less pain and controlled dissection of the space for the implant under direct vision increases precision and decreases bleeding. We're getting to the point where there are few technical steps to be discovered that will decrease pain much more. Most of available improvement involves intercostal nerve blocks with local anesthetics (which last 6-8 hours), disposable external pulsed electromagnetic field generators (PEMF) (like those made by Ivivi or ActiPatch), or indwelling pain pumps which trickle a local anesthetic in the breast pocket for 2-3 days. They all work, but have limitations due to duration (nerve blocks), external device requirements and costs(PEMF), or potential contamination of the implant from the skin (pain pumps).

I'm currently involved in some phase III FDA trials with breast augmentation on a long-acting local anesthetic that may solve all these problems. It involves bonding a local anesthetic to a fatty lipid molecule which serves to make a very effective sustained release drug. Where normally this drug (marcaine) might last 6-8 hours, when bound to this carrier molecule it lasts up to 3 days.

That is a game changer in post operative pain control IMO. It gives both proven efficacy with long action and no external devices/catheters to pay for. Our most recent patients we've done have have used nothing but tylenol for post-op for pain control, which is pretty amazing for sub-muscular implants.

Study Recruitment for Depo-bupivicaine FDA clinical trial:


Sunday, January 18, 2009

It's BOTOX Obama-nation - the left will now have have fewest wrinkles of any administration

Apparently, there is a rush on regional practices in the Washington D.C. area on politicians, celebs, high-society, and the media to get BOTOX done before next weeks inauguration.

From USA-Today:

Washington, D.C.-area cosmetic dermatologists, and skin experts in other major cities, say despite the sagging economy, requests for quickie cosmetic fixes, such as Botox and microdermabrasion, have picked up during the last few weeks as people pretty-up for inaugural fetes.

"We have been absolutely swamped since the election with people desiring rejuvenation procedures for the upcoming inauguration," says Washington, D.C., cosmetic dermatologist Tina Alster.

"My normal load for cosmetic procedures has doubled, except for hyaluronic acid fillers — Perlane and Restylane — which have almost tripled," reports cosmetic and laser surgeon Hema Sundaram, who runs two offices in the Washington, D.C., area.

I guess if you need you're skin cancer checked you're still SOL (see here for related post)in the beltway. So apparently, Democrats are not only more miserly in charitable contributions (see here), but they are more venal as well :)


Tuesday, January 13, 2009

Who's into the rough stuff? (textured breast implants that is)

There are several distinct types of ways we classify breast implants.

    • silicone or saline filled

    • round or anatomic shaped

    • smooth surfaced or textured

For the material and shape issues, there clearly are performance characteristics that differ. As to the issue of the implant shell surface, it gets a little more confusing.

The routine use of rough or textured surfaces on breast implants in the prevention of capsular contracture has been debated for nearly 20 years.
In the early 1980's we first read in the literature that the surface texture of an implant is an important variable in determining the soft-tissue response to an implant's capsule surface and experiments suggested that texturing resulted in tissue ingrowth and adherence to the implant surface.

These observations were first made with polyurethane-coated breast implants which had rough surfaces and almost no observed capsular contractures in patients with breast implants. Texturing was then quickly translated to contemporary silastic (silicone rubber) covered implants, but whether or not the same effect was maintained has been a little murky.

If (a big if) there's a protective effect from texturing, the best data I've seen suggests that it's gone as you get closer to a decade out during surgery. If I had to guess why that's so, I'd say that reflects the ruptures starting to show up in those 4th generation implants at a decade out.

It's kind of interesting to see the split between the United States and the rest of the world on this issue. Our singular experience with saline implants from 1990-2006 led many surgeons to abandon textured implants for smooth round devices as they're less likely to show visible wrinkles or ripples thru the skin. The "velcro-like" effect of the implant on it's surrounding tissue causes these ripples when the implant shifts. The rest of the world has a strong preference for textured devices as they never went through dealing with the limitations of saline implants. Philosophically, those doctors made the decision that they're willing to accept more rippling as a trade off for (possibly) less capsular contracture (implant hardening).

I personally am kind of ambivalent on this. Being an American-trained surgeon, I saw mostly round smooth implants placed partially under the pectoralis muscle during my residency. Over time, I've come to believe there's a role for "subfascial" implant techniques(over the muscle, but under the muscle fascia) with smooth implants. Looking ahead, I think we're poised to see a lot of plastic surgeons getting reacquainted with textured implants with the new shaped "gummy bear" implants which are all textured to help prevent rotation of the implant in the body.