Monday, May 10, 2010

Birmingham Breast Augmentation: American breast implant data shows more then 300K surgeries in 2009. Picking a quality surgeon.

According to recent data from the American Society of Aesthetic Plastic Surgery (ASAPS), breast implant surgery was the top cosmetic surgery performed in 2009 with close to 312,000 procedures done. Despite it's popularity, the seriousness of these operations should not be minimized. If you're choosing breast augmentation make sure your surgeon is board-certified by the American Board of Plastic Surgery (ABPS) and member of the American Society of Plastic Surgeons (ASPS). These are the benchmarks to ensure your surgeon is fully trained and qualified to perform this type of procedure.

There are many fringe organizations (a charitable description) and providers who claim they are as qualified or (shockingly) even more qualified to do breast augmentation surgery then a plastic surgeon. It's both a lie and a disservice to patients to suggest as much, but desperate times lead to desperate measures for providers trying to reinvent themselves as a nebulously described group of "cosmetic surgeons".

Quite frankly, if someone operating on your breast is not fluent or trained in techniques to do complex reconstruction or revision of the tissue they are going to leave a trail of mutilated patients trying to do operations involving breast implants as the skills and judgement for breast augmentation are learned and polished on these more complex cases. In my practice, we do hundreds of complex breast procedures annually ranging from breast augmentation to nipple sparing mastectomies for cancer. Each of these operations is individualized and brings to bear the combination of advanced surgical training and experience. To suggest that someone like the aforementioned "cosmetic surgeon", who thinks they have found a short-cut through long and difficult training, is qualified to do your surgery is wishful thinking.

The best results with cosmetic and other surgery types are when the operation is performed right the first time, while revision and redo surgery is fraught with much more unpredictable results. You owe it to yourself to research the most qualified providers for your care which will be a board certified plastic surgeon.


Thursday, April 15, 2010

FDA to mesotherapy - Put up or shut up!

The FDA last week issued cease and desist orders for a number of clinics offering fat melting "mesotherapy" injections. 
The drugs most regularly used in this process are phosphatidylcholine and deoxycholate. Other drugs or products such as vitamins, minerals, and herbal extracts are often mixed into the "gumbo", complicating any assessment of safety or efficacy. Phosphatidylcholine is not approved for injection into your body and has never been evaluated for that use in controlled settings. The new warning shot over the bow went out to six U.S clinics:
  • Monarch Medspa in King of Prussia, Pa.
  • Spa 35 in Boise, Idaho
  • Medical Cosmetic Enhancements in Chevy Chase, Md.
  • Innovative Directions in Health in Edina, Minn.
  • PURE Med Spa in Boca Raton, Fla.
  • All About You Med Spa in Madison, Ind
I would strongly advise people considering using these facilities to think again, as their disregard for patient safety with off label experimentation of these injectable concoctions should signal a general disregard for their patients. As alerts to this FDA warning went out on the ambulance chaser network of websites, expect to see ads shortly recruiting clients for lawsuits.

FYI If you are interested in reading about mesotherapy, I've written several entries about it since 2007 which can be seen here.


Sunday, April 11, 2010

Allergan reaches the finish line with FDA breast implant study!

Allergan, the world's largest maker of silicone gel implants, has announced they've reached full enrollment of the silicone breast implant follow up study group by the FDA when the devices were reintroduced for cosmetic use in 2006. This study involved registering patients undergoing breast augmentation going forward so as to better understand outcomes. We'll be watching data group for years going forward on reoperations, hardening, rupture rates, and other parameters.

We were proud to have our patients enroll in this important study since 2006 and have respect for Allergan's role in improving education of both surgeons and patients regarding proper selection and use of these devices.

Dr Rob Oliver Jr.
Plastic Surgery Specialists PC of Birmingham
(205) 298-8660

Sunday, January 24, 2010

Birmingham breast augmentation - news from the Atlanta breast symposium

Last weekend was the 2010 Atlanta Breast Symposium, one of the biggest meetings of the year for cosmetic and reconstructive breast surgery. A quick summary of highlights
  • rumors continue to swirl that form stable "gummy bear" implants will be available in the United States later this year. No one willing to go on the record with a firm date.
  • the techniques for breast augmentation using fat grafting are improving quickly in terms of reliability and predictability. The safety & feasibility of these techniques on a large scale are still debated
  • "oncoplastic" surgery techniques are advancing at an amazing rate. There are some real exciting things I can offer patients to improve their breast cancer reconstruction surgery.
2010 seems poised to be a very exciting year for breast surgery!

We offer all these advanced techniques and procedures in our practice. If you are in the Birmingham,AL area and wish to set up a consult, call my office at 205-298-8660.



Sunday, December 20, 2009

Birmingham Breast Augmentation - Balancing risk for Implants over or under the muscle

One of the questions we get asked the most during consultations for breast augmentation is whether an implant should go over or under the chest (pectoralis major) muscle. There are wide variations in surgeon and patient preferance when you survery the world on this. In general, the American surgeon is much more likely to suggest an under the muscle placement as opposed to our colleagues in Europe, South America, or Asia.

Why the difference? It's a question of risk versus benefits.

The controversy over silicone implants in the United States in the 1980's led to a rapid conversion to saline filled implants. Saline implants perform poorly under thin tissue in terms of visability and wrinkling. To compensate for this, a bias for sub muscular placments emerged to conceal the devices more. There may or may not be some advantage in terms of less hardening of the implants over time, another purported benefit.

What's the downside of submuscular placement
  • more pain post-operatively
  • potential "animation" of the devies with movement or exercise
  • gradual drift of the implant down and lateral from the contraction of the muscle
  • sliding of the breast tissue down over the muscle with age producing the "Snoopy deformity"
When suggesting the proper implant position for a patient, the most important consideration is how thick the breast tissue coverage in the upper breast is. If  a pinch of the tissue suggest 2cm+ thickness, most people have enough tissue to consider either subglandular (over the muscle) or subfascial placement (over the muscle but under the muscle fascia). Other factor we assess are skin quality (thick or thin), amount of ptosis (droop), and how physically active the patient is.

If you're a prospective patient for this type of surgery and would like to come in for a consultation, please feel free to call us at (205) 298-8660.


Dr. Rob Oliver Jr.

Thursday, November 19, 2009

The new mammogram and self exam guidelines set off a hornet's nest of controversy

The suggestions of the United States Preventive Services Task Force (USPSTF) regarding mammograms and breast self-exam have touched off a hornet's nest (to say the least) of controversy. The new guidelines recommend that women in their 40s no longer have annual mammograms and that women ages 50 to 74 have them only every other year instead of annually. After having the message drummed into American women that they HAVE to have a mammogram annually starting at age 40, why the change in advice?

The task force report explains that for every 1,000 women in their 40s who receive routine mammograms, only two cases of cancer are detected. Alongside this is the fact that 98 women will also have "false positives" mammograms which will detect something that possibly looks like cancer, but that further testing shows actually is not. The cost and morbidity of routine mammography of the population (and the subsequent workup of such lesions) therefore brings the issue of cost-effectiveness of the program into question.

Last month I wrote a post "The Return of the weregild" discussing how the cost of healthcare gets into the accounting practices of establishing how much a life is worth to society and how much we can afford in support of such a life. Although downplayed by the USPFTF, this actuarial view played some role in the decision. It is my opinion that this is actual the thoughtful way we'll have to address health care spending. Although no one wants the heath care curve "bent" at their expense, you have to look at cost/benefit of practices to the system to control spending and give yourself the biggest bang for the buck for your tax dollars.

If you step back from the hysteria, I don't particularly find the recommendations controversial. It actually reflects the world consensus re. mammograms that mammograms in younger women (<50) are a poor way to affect how many women actually die from breast cancer (the whole point of screening). No other western nation practices routine mammograms under 40 that I'm aware of (and hasn't for some time) looking at this same data. If you're going to screen younger women it needs to be done more selectively to those with strong family history or palpable abnormalities that require further workup. This is exactly what's endorsed by USPFTP and should be a model of thoughtful care for patients going forward.

My first though re. this report was actually that "I wonder how long it's going to be before insurers adopt this" and require certain guidelines be met for women less then 50 perscribed a mammogram. It didn't take long as some HMO's have said they're reviewing their policies in light of this. If you're interested there's a short article on that issue in today's New York Times.

Dr Rob Oliver

Monday, November 16, 2009

Birmingham Breast Implants - What's the role of textured implants versus smooth devices?

There are several distinct types of ways we classify breast implants.
  1. silicone or saline filled
  2. round or anatomic shaped
  3. 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.

Dr. Rob Oliver Jr.