August 20th, 2008
I hate to lure you in here under false pretense, but any person considering breast surgery should know that there is no such thing as scarless surgery. Some procedures may use different scars or fewer scars, but any operation that cuts through the skin in a human being (embryos are an interesting exception) will leave a scar. If there is no way you can accept a scar on the breast, you shouldn’t have a cosmetic breast operation. When it comes to breast augmentation, the most common approach is through an incision about 3.5 – 4.0 cm long in the inframammary fold (the crease just under the breast). I just returned from a meeting related to breast surgery and body contouring and an electronic survey of the board certified plastic surgeons in the audience disclosed that 87% of us use this approach as our standard way of doing the case. I was interested to note that there were data presented that suggested the approaches using incisions in the nipple, arm pit (trans-axillary) and umbilicus (TUBA) are associated with more problems and higher ultimate revision rates than the inframammary approach site. Additionally, if there are any problems encountered during the operation, such as excessive bleeding, when using one of the more remote approaches (trans-axillary and TUBA) then an inframammary incision must be performed in order to control the situation thereby leaving two scars on the breast. Breast augmentation carries with it a reasonable risk that the patient will have a revision operation at some time in her future due to things like rupture of the implant or tightening of scar tissue around the implant (capsular contracture) and these operations frequently are not able to be performed through these remote incision sites, again, leading to an incision on the breast.
As you can no doubt tell, my preferred access site for breast augmentation is the inframammary site. I feel that from here I can offer my patients the best result attainable because it gives me the most precise control over the technical aspects of the operation and avoids opening the breast ducts (which the nipple approach may do) and exposing the implant to bacteria. Some research supports that exposing the implant to possible bacterial contamination by passing it through surgically opened ducts (as is commonly done using the nipple approach) leads to a higher capsular contracture rate.
In the end, I want to provide my Katy and West Houston patients with the highest quality breast augmentation available using state-of-the-art techniques that research has shown leads to more consistent results with lower re-operation rates and fewer complications
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July 28th, 2008
This is a question frequently asked by patients during their process of screening plastic surgeons. While I appreciate anyone’s attempt to assess the experience and technical capabilities of a surgeon before deciding to use them, this question by itself is not, in my opinion, a good way to get a feel for the level of craftsmanship a surgeon puts into his or her work. Are you more likely to get a better breast augmentation from someone who does 5 breast augmentations a day or one who does 5 per week? Would you feel more comfortable being someone’s fifth case of the day or their first? Would the surgeon feel good if their loved one were someone’s fifth breast augmentation of the day?
The point I’m trying to make here is that while it is certainly important for the surgeon being considered to have adequate technical experience and practice with the type of operation you are planning, this number alone does not imply the level of craftsmanship you can expect from the surgeon.
I like to play the guitar. I have been doing this avidly since I was 12 years old (and that would be 38 years now!). As many of you who either play or know someone who plays knows, a guitarist cannot have too many instruments. They are like putters to golfers. There’s one for every occasion and sound you might want to produce. In general, experienced builders producing the finer instruments do not produce in mass quantities. Therefore, in this instance it is not correct to conclude that you’re more likely to get a better instrument from someone who builds 300 guitars per year versus a builder who produces 50. There is a different frame of mind and philosophy of business associated with these types of producers and, I would argue, you will find something similar in your search for a good surgeon.
Surgery is a physical thing like the application of any skilled handcraft and produces fatigue. Additionally, there is the pressure of the surgeon’s office schedule to attend to. If he or she is running late for office and you are the next patient on the surgery list, are you sure you’re going to get the attention and craftsmanship you are paying for in the operating room from a fatigued surgeon under this time pressure? Also, are you sure that the surgeon you enlist is doing the entire operation from start to finish or, in the interest of mass production, are they outsourcing things like closing the skin incisions to assistants? Do you get long periods of quality time with the surgeon to discuss any issues you may have before and after the surgery, or does he or she breeze in, tell you what surgery they think is best for you, breeze out and leave you in the hands of patient care coordinators to get you into and out of the assembly line? Don’t get me wrong; I don’t think that this style of practice is unethical or immoral in any way. It is just different. You should have some sense about which type of environment suits you best and the numbers don’t always reveal the truth here. The only thing the numbers reliably indicate is the surgeon’s income; not the quality of operation or treatment that you can expect. So, it’s ok to ask about the surgeon’s volume, but it is also very important to realize how volume effects quality.
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July 24th, 2008
Many patients seeing me for the first time for a cosmetic surgery consultation feel in some way guilty or ashamed for talking to me about their issue. These feelings, I am sure, arise for various reasons in different people but, whatever their origin, the end result is the production of the same feelings when they consider changing the appearance of their bodies with surgery. I start out by telling them that almost everyone has some critique of their form when they mentally compare themselves to their ideal. (I, for one, wish I had broader shoulders, but unfortunately, there is no ready solution for that problem.) I then go on to mention that concern for our appearance is thought, in general, by our culture to be a good trait. We busy ourselves for many hours during the week with activities to make ourselves physically attractive. We bathe, cut and color our hair, shave, brush our teeth, work out, choose our clothing and jewelry carefully for each occasion, decide whether or not we will get a tattoo, etc. We do this because we know that we will be judged by others, at least initially and for the largest part unconsciously, based on our appearance. This trait, like it or not, is in all of us and relates in a primitive way to basic survival instinct. We must readily ascertain if someone looks threatening or not (“friend or foe”) and the stage upon which these judgments are first formed is the stage of appearance. Very often, initial feelings of like or dislike are formed based on a subjective “sense” we get from someone’s appearance. Additionally, we have excellent statistics that show how some human features and proportions are cherished as beautiful regardless of cultural background. These would include things such as skin quality, facial symmetry and basic body shapes. Furthermore, like it or not, studies show that individuals widely regarded as attractive in our society tend to be promoted more, make higher incomes and are less likely to get laid off in the event of a down-sizing. Interestingly, it seems to be the opposite for attractive women in the legal profession who are less likely to make partner than a less attractive colleague of similar ability.
When I point out how we are always concerned with our appearance and how we frequently go about changing the way we look, we begin to see cosmetic surgery as an inevitable technological extension of this powerful innate drive to enhance our feeling of self-satisfaction by adjusting our appearance. It is not so much that we have a problem changing how we look; it is the concept of using this technology to effect more profound changes at levels heretofore unattainable by traditional means. It is important that making the step to cosmetic surgery as the next point in this continuum be safe. If it were particularly risky, then it would be unreasonable. Fortunately, the advances of modern medicine, surgery and anesthesia techniques have brought the risks of life threatening complications down to levels that are significantly lower than the mortality risk for driving your car, an activity we engage in daily with the full knowledge that many people die behind the wheel daily in our country. Driving is a very acceptable risk to us. For healthy individuals, the risk of serious or life threatening complications associated with cosmetic surgery is far below that for motor vehicle operation, bringing the risk profile to a level consistent with using surgical techniques for cosmetic enhancement.
Often, by the time I get to this point in my explanation, the patient’s initial feelings of guilt have been assuaged as they have come to understand that the use of cosmetic surgery to alter appearance (when properly and ethically employed – see “Expectations and Patient Satisfaction” and “It’s OK, give yourself permission” blog posts) is just a technological extension of something human beings naturally seek to do; maximize their feeling of confidence by putting forth a physical appearance they feel represents their true selves in the best light possible.
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July 7th, 2008
I can say unequivocally that the answer to this question is yes and no! I don’t mean to be vague or evasive, but what happens here is directly related to how we put on fat. The fat cell (lipocyte) is nothing more that a storage container. It looks a lot like a bubble and when we gain weight fat, the bubble blows up and becomes larger; we don’t make more fat cells. When we lose fat, the bubbles shrink. The fact that fat cells are essentially non-dividing is the key to understanding how your appearance might change after liposuction and how your body will behave with any gains in weight. As many of you know, there are shapes related to our bodies that, no matter how much we exercise and watch our diets, we can’t change. The example I like to use is that of the saddle bags that some women have on the outside of their thighs. No matter how much they try, they can’t get these to go away, they are just larger or smaller versions of the same shape with gains or losses in weight. You cannot spot reduce a fatty by, say, exercising the outside of the thighs more. It just doesn’t work that way. In order to change this shape, the fatty tissue must be removed. This is a great job for liposuction. The fat cells are removed, the skin shrinks in and the shape change we have made is permanent. If the patient gets heavier, she will not reproduce this same contour because we have removed the non-dividing fat cells from this area and no new ones will arise to take their places. However, since there are fewer cells for the storage of fat there, the body will just look to other places to put fat when the need arises. If this hypothetical patient were to gain a massive amount of weight, it is likely that the areas treated with liposuction would appear as indentations in the sides of the thighs because the rest of the thigh would be able to plump up normally while the treated areas would not. If large areas of the body are treated and considerable weight is gained afterward, the patient will put fatty tissue wherever fat cells are available, such as the face, arms and intra-abdominal storage sites. In addition to this, the treated areas will become lumpy and uneven in appearance as the distribution of fat cells is not completely smooth, so those areas with a slightly greater population of fat cells may gain more than the surrounding areas.
Liposuction is not for weight loss. It is for shape change. The mirror, not scale, is the place to evaluate results and all results must be maintained. Large weight gains will spoil the results, and can produce shapes that are less desirable than those for which liposuction was originally employed to remedy.
David Luethcke, MD, FACS
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June 30th, 2008
Modern plastic surgical techniques competently practiced are exceptionally safe but a factor that is beyond the limits of any surgeon to control is what the patient expects and wants to get from their surgery. It is critically important for a surgeon to establish an understanding of this at the initial consultation visit. I have to talk with my patient enough to get a good feel for what they are looking to accomplish with a procedure that changes their appearance and if there are any underlying issues that affect body image and may adversely impact their perception of the result. Good candidates for surgery can clearly explain what aspects of what features on their body they want to change and why. These changes should be undertaken only for that particular patient’s needs and not the needs of any one else such as spouse, significant other, a particular social group or parent. Additionally, it is not reasonable to expect changes in appearance to result in significant social changes such as the salvage of a troubled relationship, a promotion or raise at work or the furthering of a career in the performance arts or modeling. The issue that concerns a patient must be easily observable by me and I must agree that it lends itself well to surgical correction. Plastic surgery, while in general quite precise, is not like working in wood or metal where what you see when the operation is complete is exactly what you have as a final result. The amount of changing a result goes through post-operatively can be quite extensive and varies in degree from individual to individual for any given procedure. This “fuzziness”, or degree of imprecision, makes the precise prediction of what someone will look like after surgery impossible and I must feel that the patient can tolerate this before they are considered a good candidate for surgery. If I get a sense that they will be unsatisfied if the final result varies in any way from their desired result, I do not recommend surgery.
Another very important concept to get a handle on is that every patient’s result after surgery looks unique. This is because every patient is uniquely shaped. When I see patients for breast augmentation consults, I like it when they bring photos of results that they like. They will often make comments on results they don’t like such as “These breasts go out too much”, or “These are too low”. What they are actually observing are the individual differences in patient appearance related to the anatomical shape of their skeleton and soft tissues and not issues related to the technique of the operation, implant size, shape, etc. It is crucial for a patient to understand what elements of their look can be affected with the operation and what elements cannot. This can prevent misinterpreting certain natural features of a person’s look with issues directly related to the surgical technique. My patient’s laugh when I tell them “I would really like to find a plastic surgeon that could make me look like George Clooney!” because everyone knows, at least at this level, that you cannot fundamentally change certain things about how you look. This concept is not only true in the above rather silly example, but it extends to the whole body.
These things being said, I find that, by far, most of the patients who see me for consultation are very realistic in their expectations of what plastic surgery can accomplish and, as importantly, what it cannot accomplish and are excellent candidates for surgery from this perspective. If my patient realizes what their unique appearance is bringing to the operation and how it will influence the final result, then he or she is much more likely to elect to have surgery for the proper reasons and have reasonable expectations about what plastic surgery can achieve for them. This all leads to a much higher chance of them having a satisfying outcome.
David Luethcke, MD, FACS
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June 24th, 2008
This is a very important question to answer in breast augmentation surgery. Every patient has their ideal goal in mind when they come to see me, but it’s important to know that we can’t make any size and shaped breast we want to on any one’s body. All cosmetic surgery tries to make the most of what is naturally yours and, while there are some things we can change, there are a number of others that we can’t. For instance, we can’t change the size and shape of the rib cage, and this is highly influential in determining which direction the breasts orient themselves (outwardly pointing, or more straight), how the breasts are positioned relative to each other (far apart or close) and how the bust line appears on the torso (best on a rib cage that tapers to a nice waist). We cannot change the tightness or quantity of the patient’s skin and we cannot change the over all body style, size and shape of a patient. All of these qualities influence the final result and that is why each and every result is unique. I consider it of vital importance during consultations to communicate this to my patients and help them understand how their unique shape will effect their ultimate result.
Then, there’s the whole size thing. It’s vital to know that we cannot stretch the skin of the breast as much as we want to with implants. Over-stretched skin gets too thin and provides inadequate and unstable coverage for the implants. In turn, this creates a situation that will increase the chance that the patient will need another operation to fix an implant problem in the future. The right size implant is one that has the right diameter to fit accurately under the breast and enough projection (thickness of the implant) to accommodate the tightness or laxity of the breast skin. There is already a significant re-operation rate associated with breast augmentation and I want to do the best I can to keep this as low as possible for my patients while trying to help them attain their goals. A great deal of information relating to the implants themselves and breast augmentation surgery can be found on the Mentor Corporation’s web site at www.mentorcorp.com. There’s also a lot of great information on www.loveyourlook.com.
So, the best size implant for a breast augmentation patient is one that helps her get as close as possible to her goal size, but respects her natural proportions and skin tone. Using these techniques, we can produce enhanced breasts that are in harmony with your natural proportions and keep the risk of future surgery as low as we can.
David Luethcke, MD, FACS
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June 22nd, 2008
During the course of my workweek, I usually run across a couple of patients in consultation who feel guilty about consulting me to change some aspect of their appearance. They feel almost like they are betraying themselves because they have this aspect of their appearance that they would like improved. It seems wrong to them that they should not be happy with the features they have or content with the changes that have occurred over the passage of time and having a child or two…or three.
It is very interesting to me how these consultations go. Some patients are comforted when I share with them that plastic surgery isn’t supposed to make you “funny looking”; it’s just supposed to minimize certain distractions the patient (and probably no one else!) sees in themselves. I tell them that they walk by people every day on the street that have had plastic surgery operations and they are unaware of this because these people look perfectly normal. And that’s the point. Not to make a bizarre, attention-attracting look, but to make a perfectly normal appearance that inspires increased self-confidence and doesn’t convert one aesthetic problem into another one!
As I discuss possible surgical options with other patients, they become certain that indeed plastic surgery is not for them, and this is OK too. The whole purpose of the consultation is to help the patient come to a decision that is right for them and not for anyone else. As practitioners of the art of plastic surgery, it is not right for us to sell people operations. We need to listen carefully to each individual and come to a plan together and sometimes this plan does not involve surgery.
Even if you’re not sure if plastic surgery is for you, you should give yourself permission to have a consultation and here you may find that you are comforted by the safety and skill with which modern plastic surgery is practiced or you, with the help of the surgeon, may come to the conclusion that it is not for you. Either way, you win.
David Luethcke, MD, FACS
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June 18th, 2008
Choosing a plastic surgeon can be a daunting and confusing task. This is compounded by the fact that there are no state or federal regulatory requirements concerning the training and experience an individual must have in order to use the title “plastic surgeon”. Hopefully, this brief piece will help you organize your evaluation process and allow you to pick a well-qualified and safe surgeon that will not only perform well in the operating room, but also be there after surgery for any follow-up, questions or issues you may have.
A surgeon’s formal training is the most critical element to evaluate. They should be board certified in plastic surgery by the American Board of Medical Specialties (ABMS). This is the principle board certifying organization in the United States. It is not illegal for any one to form any board they wish and “certify” individuals who have no formal training in plastic surgery at all. Indeed, some have no formal surgical training whatsoever! You can verify ABMS certification at their web site, www.abms.org.
Once proper board certification status is verified, you can check for additional experience and qualifications in aesthetic (cosmetic) plastic surgery by looking for the surgeon’s membership in The American Society of Aesthetic Plastic Surgeons (ASAPS). Their web site is www.surgery.org. The two main professional bodies of board certified plastic surgeons in the United States are The American Society of Plastic Surgeons and ASAPS and one should definitely establish that any surgeon they are considering for cosmetic plastic surgery is recognized as a member of these societies. The potential surgeon should also have privileges to perform plastic surgery at local hospitals and not just in their own operating room. Doctors must undergo examination of theri training and professional history in order to pass a peer reviewed process to get privileges to work at the hospital and this is not so of operating rooms owned by the physician. Don’t get me wrong here, excellent outcomes can be had from either of these operative settings, but there is no independent peer reviewed vetting of the surgeon’s credentials for his or her own operating room.
Another good source of information on plastic surgeons in your community may be your own personal physician (family practice, internal medicine, obstetrics and gynecology, etc.). If you have a good, established relationship with such a physician, ask them for referrals or recommendations.
Once the adequacy of a prospective surgeon’s credentials has been established, you should schedule consultations with at least a few offices to get a feel for how you like the surgeon and office staff and how they handle patients and what the surgeon’s individual level of expertise is with the issues in which you are interested. Not every patient will feel comfortable in every office and there are many different personal styles of practice. You should, however, feel that your prospective surgeon is listening closely to your issues and explains his or her proposed line of treatment thoroughly. Moreover, there should be sufficient time for you to ask questions and receive detailed answers. It is important, I think, to understand how a surgeon approaches potential issues like the occasional need to revise an operation or scar. Is there a charge for these services should they be required, and if so, how much? Also remember that your care goes beyond the operation itself. Do you have a sense that this individual and staff will be there for you during recovery if you have questions or concerns?
Hopefully, this puts a few tools in your kit when it comes to looking for a well-qualified and safe plastic surgeon. If you need any additional information about us or would like to schedule a consultation, give us a call at 281.829.0000, or check out our web site at www.westsideplasticsurgery.com . Have a great day.
David Luethcke, MD, FACS
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June 17th, 2008
“My approach to the practice of plastic surgery is highly individualized. I believe the best results are obtained by first carefully listening to the patient’s concerns and then designing treatment that specially targets these objectives.” — David R. Luethcke, M.D., F.A.C.S
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