Who Gets Plastic Surgery?

One thing that I continue to be impressed with is the wide cross section of people who come to us for plastic surgery. We see people of all ages. Men and women. Every ethnic group. From all over the local area and from all over the world. People seek Palm Springs plastic surgery, just like people from Beverly Hills, the Valley, or the South Bay. The most interesting thing is that the motivations are similar even for these diverse people. They want to feel more comfortable with themselves. Yes, it is about appearance. But it is really about how comfort with appearance allows people to be more comfortable with themselves overall. So the answer to the question, "Who gets plastic surgery?" is that many different people do. And that the reason that all these diverse people do is to enhance their overall comfort levels with themselves and their lifestyle.
At Rodeo Drive Plastic Surgery, in addition to the usual cosmetic surgery procedures such as Los Angeles tummy tuck and
breast augmentation, we also provide innovative breathing surgery.

Below are excerpts from two articles about a unique procedure to help people previously confined to a ventilator for life. The research behind the procedure and its development was done by Abbott Krieger, MD, the father of our Medical Director. Dr. Abbott Krieger did basic research on the concepts for this revolutionary surgery. He then pioneered its use clinically. The procedure uses a nerve transfer technique to allow the phrenic nerves to once again stimulate the diaphragm to move air, allowing patients to breathe without the need for a ventilator.

From New Scientist---
PEOPLE who face spending the rest of their lives on ventilators may be able to breathe on their own again with the help of a new surgical technique.

To help people breathe normally when they're disabled by spinal cord injuries, surgeons often implant a pacemaker that stimulates the phrenic nerve, which cues the diaphragm's breathing motion. But this doesn't work if the nerve has also been damaged. Now Abbott Krieger, a neurosurgeon in Livingston, New Jersey, says that he can repair phrenic nerves so they respond to the pacemaker.

Abbott Krieger MD takes a nerve that goes to a chest muscle and grafts it on to the dead phrenic nerve. After a few months, he says, the phrenic nerve becomes functional again and the pacemaker works—so the patient can live without a respirator.

Neurosurgeons use this type of nerve grafting to repair more peripheral nerves such as those in the face, but never in the deep chest cavity where microsurgery is difficult. Krieger's procedure was successful in five out of the six patients he treated, he told the Congress of Neurological Surgeons in Boston this week.

From Plastic and Reconstructive Surgery---

The Intercostal to Phrenic Nerve Transfer: An Effective Means of Reanimating the Diaphragm in Patients with High Cervical Spine Injury

Nerve transfers have been well described for the treatment of congenital and traumatic injuries in the brachial plexus and extremities. This series is the first to describe nerve transfers to reanimate the diaphragm in patients confined to long-term positive pressure ventilation because of high cervical spine injury. Patients who have sustained injury to the spinal cord at the C3 to C5 level suffer axonal loss in the phrenic nerve. They can neither propagate a nerve stimulus nor respond to implanted diaphragmatic pacing devices (electrophrenic respiration).

Ten nerve transfers were performed in six patients who met these conditions. The procedures used end-to-end anastomoses from the fourth intercostal to the phrenic nerve approximately 5 cm above the diaphragm. A phrenic nerve pacemaker was implanted as part of the procedure and was placed distal to the anastomosis. Each week, the pacemaker was activated to test for diaphragmatic response. Once diaphragm movement was documented, diaphragmatic pacing was instituted.

Eight of the 10 transfers have had more than 3 months to allow for axonal regeneration. Of these, all eight achieved successful diaphragmatic pacing (100 percent). The average interval from surgery to diaphragm response to electrical stimulation was 9 months.

All patients were able to tolerate diaphragmatic pacing as an alternative to positive pressure ventilation, as judged by end tidal CO2 values, tidal volumes, and patient comfort. Intercostal to phrenic nerve transfer with diaphragmatic pacing is a viable means of liberating patients with high cervical spine injury from long-term mechanical ventilation.

Cohesive Gel implants



A few weeks back I promised to continue discussing some of the evolution in contemporary breast reconstruction. Most of that post had to do with past. This one's about the future. The future is the cohesive gel implant with or without a latissimus flap. This is for a couple reasons.

1. As I mentioned earlier, no one is going to subsidize the more labor-intensive reconstructions (ie. TRAM flaps, Free TRAMS, and the various perforator flaps - DIEP,SIEP,Ruben flaps,etc..)

2. The form-stable cohesive gels can look great with very little work, even in patients with thin skin flaps following mastectomy

Seen above is a cut section of the Inamed 410, a textured and anatomic-shaped implant that's fairly far along in the FDA approval process. It uses a silicone gel filler that's cross-linked much more then the traditional gel implants. This gives it the "gummy-bear" feel that patients have described it as.When the shell is cut or ruptures, the filler goes nowhere. This completely eliminates the migratory silicone gel that can cause some local issues in the breast or enlarged axillary lymph nodes. The safety data coming in on the 410 style blows away the currently FDA approved saline and silicone implants already sold. (NOTE: Mentor Corp. also makes a high-cohesive gel, the CPG, which is slightly behind Inamed's 410 in the approval process)

It's been used continuously since 1994 in Europe, and is the most popular style of implant for both reconstructive and cosmetic breast surgery in the world. Surgeons in other countries are amazed at the fact that the United States is still debating about 30 year old implant designs while they've already moved beyond that.

An excellent summary of the 410 cohesive can be found here

Update: Plastic Surgery for Men

We continue to see increases in men having procedures. Our most popular procedures are liposuction, male breast reduction (male breast reduction), and rhinoplasty. There seems to be less hesitation when it comes to plastic surgery for men. Guys are just getting more comfortable talking about their bodies and seeking improvements, whether they be large or more subtle. Check out our video about the subject, it is the highlighted link on this post.

Face transplant debacle


Once again, French Surgeons led by Dr. Jean-Michel Dubernard have managed to set back both science and professional ethics in attempting a poorly planned surgery. Recently the world first "partial" face transplant (consisting of the cheek soft tissue on one side) was performed by his team in Northern France.

If you'll remember, Dr. Dubenard also has the claim to fame of the world's first hand transplant. The common denominator in both case is a rush to be "first" to do a radical surgical procedure while ignoring ethical concerns and half-assed patient selections for his human experimentation.

The first hand transplant was placed on a borderline paroled Kiwi con-artist, Clint Hallam. Predictably this fellow abruptly disappeared from follow up, quit taking his immuno-suppression meds (required to keep his body from rejecting the transplant), and showed up some time later with a dead,mummified hand requiring amputation.

This recent face transplant patient was a young women who reportedly tried to commit suicide with tranquilizer and who face was mauled by a pet dog while she lay unconscious. This alone should have disqualified her from consideration, but did that stop Dr. Dubenard? Of course not.

Well today we see an article that the patient is being non-compliant and has begin smoking, a HUGE risk with a recent microsurgical tissue flap, as nicotine will make the nutrient artery spasm with the flap dying shortly thereafter. Also mentioned from the same article is that fact that a number of previously reported successful hand transplants have failed as patients can't afford their required immunospression drugs or have been non-compliant with their regimines.

These failures only highlight the processes setup at the University of Louisville & the affiliated world-famous Kleinert,Kutz, and Associates hand surgery practice(where I trained) and the Cleveland Clinic which have setup extremely rigorous exclusionary criteria involving not only appropriate physical attributes, but also extensive psychological profiling,testing, and counseling to avoid these problems Dr. Dubenard has predictably encountered. In fact, Dr. Dubenard's team essentially high-jacked the immunosuppression model designed and developed in Louisville (of which I had a very small part in some of the related bench research) while abandoning any pretense of careful patient screening.

Rob Oliver
www.oliverplasticsurgery.com

Breast reconstruction in evolution - part I

Up until about 30 years ago there really was no such thing as breast reconstruction. Flap-based reconstruction was just being conceptualized by pioneers John McGraw, Luis Vasconez , Carl Hartrampf, & John Bostwick. Tissue expander technology was in its infantcy. Microsurgical techniques were primitive. Surgeons trained up until that point had no experience in this area.

In the blink of an eye came Bostwick's Latissimus flap/implant procedure, Carl Hartrampf's TRAM (transverse rectus abdominus myocutaneous) flap, and Radavan's tissue expander reconstruction. Unsatisfactory results from early expander + implant reconstructions led to wide-spread popularity of the TRAM flap. As microsurgery matured "free flaps" (the blood supply to the muscle/skin island is isolated,dived, & sewed back in where the tissue is required) were designed and flourished at many training programs and tertiary hospitals.

Recently, a new reportedly less-morbid variant of the free-TRAM has been advocated by New Orleans surgeon, Bob Allen called the DIEP flap. This procedure involves tracing the small perforating vessels thru the rectus muscle & leaving the rectus muscle behind. Proponents argue that this is the most elegant & least morbid autologous reconstruction available. A number of DIEP-performing plastic surgeons have gone so far as to label the traditional pedicled TRAM obsolete.

What's a patient to do when presented with these complex choices?

I think what's telling is that when a panel of female plastic surgeons recently at the Annual Plastic Surgery Society meeting, the majority of them would NOT select TRAMS for their own reconstruction as first-line reconstruction (expanders were most preferred)and a number of free TRAM/DIEP performing surgeons in the audience expressed doubts over the cosmetic superiority of free flaps over the pedicled TRAM or Latissimus+implant reconstructions.

Plastic Surgery Without Pain

Prior to undergoing plastic surgery, many of our patients express concern about how much pain they will have during recovery. To meet this concern, we have taken steps that work to minimize post-procedure pain. We call our system Rodeo Drive Plastic Surgery Rapid Recovery.

While it is difficult to make any surgery completely pain free, we have succeeded in making our procedures very low pain. This allows patients to be comfortable from the moment the procedure is completed and our nurses take care of them in the recovery room, to when they continue their recuperation at home. Our goal is to make post-procedure pain something akin to the soreness that accompanies a very strenuous workout at the gym. This applies to all procedures, everything from Beverly Hills liposuction to tummy tucks.

Many of our patients travel from out of town, so Rodeo Drive Plastic Surgery Rapid Recovery helps them remain comfortable in the unfamiliar environment of a hotel, in the car for a sometimes long drive, or on the plane flight home some days later.

The program involves our surgeons, anesthesiologists, nurses, and patients all working together to minimize pain. Each of these individuals has a key role in working to minimize post-procedure pain.

Rodeo Drive Plastic Surgery Rapid Recovery begins well before surgery day. This phase takes the form of educating patients about the program and the steps we will be taking to minimize pain. Once concerns are alleviated, patients continue the process toward surgery much more comfortably. The program continues during all aspects of surgery through recuperation at home.

Rodeo Drive Plastic Surgery Rapid Recovery consists of these steps:

--Providing patient education before surgery

--Giving patients prescriptions for narcotics and anti-nausea medicine for their recuperation

--Using a physician anesthesiologist during every cosmetic procedure, to ensure patient safety and to administer pain and anti-nausea medications during the surgery

--Doing all our procedures in a AAAHC and Medicare certified surgery center, to assure the highest standards in our patient care, safety, medications, sterility, lighting, and equipment

--Employing extra-gentle tissue handling techniques during plastic surgery, to minimize trauma and resulting pain

--Applying long-acting local anesthetics to all surgical sites at the end of the procedure, so pain centers are not stimulated during early recuperation

--Communicating with patients when they first awake using a nurse-patient interactive pain picture chart, and giving pain medicine as soon as patients report discomfort – before the onset of any true pain (see picture chart above)

--Remaining in close contact with patients during their recuperation, to make certain their pain is controlled -- and altering pain medicines if necessary

Patient response to Rodeo Drive Plastic Surgery Rapid Recovery has been excellent. It is important to stress, however, that even though patients may have very little pain following surgery they must still limit their physical activities so their recovery can proceed without complication.


Lloyd M. Krieger, MD is a California cosmetic surgeon and the founder and medical director of Rodeo Drive Plastic Surgery in Beverly Hills, CA. Specializing in Nip/Tuck Rodeo Drive, Dr. Krieger offers all plastic surgery procedures. And while the center has many clients from the entertainment industry, they offer more than just celebrity plastic surgery! Dr. Krieger welcomes your questions and comments by calling our Los Angeles plastic surgery center at 310-550-6300 or by email at info@RodeoDrivePlasticSurgery.com.

More information can be found at http://www.rodeodriveplasticsurgery.com/.

Silicone Gel's future

There's a lot of interest from patients about silicone gel breast implants. Since the early 1990's there's been an FDA moratorium on unrestricted use of gel implants. To make a long story short, in a political maneuver not support by science, the implants were severely limited to IRB-guided protocols for cosmetic & reconstructive use. Since then, silicone implants have been overwhelmingly shown to be both effective AND safe in trials all over the world. Presently, only the United States & South Korea (which defers to the FDA in many issues) have such restrictions.

Last fall, the FDA advisory panels gave approval recommendations to Mentor Corp. to remove the current restrictions. Game over, right? Well in 2004, Inamed Aesthetics likewise passed the advisory panel only to be shut down later on. (Ignoring the science advisory panel is a VERY rare event BTW)

Funny enough, the implants being considered currently are 20 year old designs. Some people label them "3rd generation" implants. They were designed and are manufactured with QA much better then previous implants. Most of the horror-stories of patients with silicone were "2nd generation" & suffered problems related to the low viscosity of the silicone gel & thin shells that surgeons of that era were asking manufacturers for. From the mid-late 1980's on, implants were made with both good durability and efficacy.

Coming down the pike are the cohesive silicone gels which feature much higher viscosity gel. These are the "Gummy Bear" implants you might hear about. They represent potential advantages of being form-stable (rather then more like a liquid) and impart real shape-defining characteristics to the breast.

Check back soon for a diary with more about the cohesive gels!

A Novel Approach to Breast Reduction


At Rodeo Drive Plastic Surgery, we are always trying to take advantage of our environment here on Rodeo Drive. The fashion boutiques next door and down the street give us a lot of information about style and trends. One way we recently did this is with our approach to breast reduction surgery.

Breast reduction surgery has the potential to greatly improve quality of life. For people with overly large breasts, the symptoms of neck pain, back pain, headaches, and limitations on activity often can be instantly alleviated by breast reduction surgery.

Among plastic surgery procedures, breast reduction is especially challenging. The three dimensional nature of the breasts, combined with the need to change their position and shape in addition to size, makes breast reduction surgery a complex undertaking. We have found that people coming for breast reduction surgery are seeking to improve not only their appearance but their overall lifestyle. They want to look better and feel better. They want to be more active. They want to wear elegant clothes that have previously been off limits to them.

To meet our patients’ goals, we looked to our neighbors on Rodeo Drive. We worked with these boutique managers and style makers to better understand the types of body shapes that best fit into fashionable clothing. In each breast reduction procedure, we not only address breast size, but also their shape and position. This way, the final breasts after our Los Angeles breast reduction match the body to create a harmonious overall shape. We call our approach the Rodeo Drive Shaped for Fashion Breast Reduction.

Our goal for Beverly Hills breast reduction is to create the size and shape that will allow our patients to look good, feel comfortable, and give the widest options for wearing all types of fashionable clothing. Our Rodeo Drive Shaped for Fashion Breast Reduction goes beyond simply reducing the size of the breasts. it joins many of our other procedures we are proud to innovate for our patients, such as our novel neck liposuction procedure, among others.

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