Vol. 5, No. 5- January 2008

Welcome to our January 2008 Newsline

All of us at the Cosmetic Surgical Center hope that each of you had a wonderful Holiday Season. 2007 was a great year for us and we are pleased to report that our practice exceeded all previous years in services delivered. Since our practice is now entirely referral based, this especially pleases us and convinces us we are providing the highest quality of service. We strive to exceed the expectations of our patients and we will always attempt to improve.

Staff Additions

We have had two very important additions to our staff. First of all, our new Fellow, who actually started last year, is Dr. Victoria Karlinsky, who comes to us from New York, having completed a residency in General Surgery graduating with the highest honor, as the Chief Resident of the Year, More information about Dr. Karlinsky can be found on our website under the link: Karlinsky bio.

As many of you remember, and as we reported in our last Newsline, Amelia, our wonderful Doberman who greeted and calmed so many of our patients died last July. Late in October, we flew out to Tennessee and adopted our new Doberman, Jeta. She is often seen at the Center and is charming all of us - patients and staff alike. Hopefully, many of you will meet her when you return.

In spite of our best efforts, capsular contracture, or firmness, is a not uncommon after effect of breast augmentation. While some patients will chose to live with the condition, many seek correction. This can be for a number of reasons. In some cases, the condition is painful or uncomfortable enough to warrant correction. It may cause distortion of the implants or a repositioning of the breast. Radiologists have a much more difficult time carrying out mammography when implants are encapsulated.

Years ago, the condition was treated by forcefully squeezing the implant to break up the surrounding scar tissue. It was rather barbaric since it was often done as an office procedure without sedation or anesthesia. The bigger problem was that it often not only broke open the surrounding capsule, but the implant as well, resulting in gel leakage into the body. The procedure was abandoned in the early ‘90s and is rarely if ever done now. The treatment now requires a surgical approach which allows direct release of the contracture.

About 15 years ago, as a result of our experience with endoscopic breast augmentation, we developed a technique of endoscopically releasing capsular contracture through a tiny incision (about half an inch) beneath the nipple. The technique utilizes a laser which cuts through the capsule. The technique is described on our website, and the following two links will give you some general information about it: endo capsulotomy article endoscopic capsulotomy info.

Because of the large number of inquiries we receive about the procedure, I thought I would try to answer some of the more common questions we receive.

17. What is the advantage of this technique over others? There are two primary advantages. One is the very tiny incision. The other, which is more important, is the fact that the laser makes the procedure bloodless in nearly every case. Since we know that blood in the implant pocket is one of the most common causes of capsular contracture, it makes sense that this would help to reduce the rate of reoccurrence of capsular contracture.
17. Can the procedure be done anywhere but Abilene? Unfortunately, at the present time, no. We have been working with several surgical instrument companies in an effort to make the equipment available to other surgeons, but so far, none have produced a device that meets our standards. Many surgeons have indicated interest in the procedure and we hope to eventually have the equipment available.
17. How long do patients have to stay in Abilene following the procedure? We recommend that patients stay in town at least a day after the operation. 
17. What are the major risks? Infection or bleeding would be the most likely complications. These have been extremely rare and only have occurred in isolated cases with unusual surgical findings.
17. What special follow up care is required? Nothing specific. We do recommend against any aggressive physical activity for a few days, primarily because of the theoretical possibility of causing subclinical bleeding which could promote recurrent encapsulation.
17. Are drains or special dressings required? No, unless there is a very unusual finding, no drains or dressings are used. In fact, we do not even use skin sutures since the incision is so small. Small tape Steristrips are applied over the incision. These fall off in a week or so.
17. Can this procedure be done if a patient has gel implants? Sure. However, if we find at the time of procedure that there is leakage through the implant, the operation can not be carried out. Patients will then be faced with the decision of what to do about their leaking implant.
17. Can the procedure damage the implant? Yes, it is possible. However, so far we have not faced this complication. The endoscopic device is designed to shield the implant from the laser beam.
17. Is the procedure painful? For most patients, no. Of course pain is very subjective, but the procedure is rarely perceived as painful - certainly not as painful as the original augmentation. Most patients are back to normal activity the day following surgery.
17. Can the procedure be repeated? Yes, it can. Several of our patients have had it repeated. Occasionally, patients have experienced longer term success with a second procedure. However, there are some patients who will continue to develop capsular contracture. Our general recommendation is to try the endoscopic procedure a second time, and if contracture returns within a relatively short time, consider a more comprehensive operation such as capsulectomy (complete surgical removal of the old capsule).

LipoDissolve, a form of mesotherapy restricted by state authorities

There has been a lot of publicity regarding a technique called LipoDissolve, in which certain chemicals are injected under the skin supposedly to dissolve fat, tighten skin and reduce stretch marks. According to the The Physicians Coalition for Injectable Safety, there have been reports of complications that include skin infection, disfigurement, severe cramping, bloating and dehydration. Recently the Kansas State Board of Healing Arts has restricted the use of this technique to physicians who are working under an investigational drug trial.

Mesotherapy, which is the term used, in general, for this type of injectable treatment, has been touted for a multitude of conditions and ailments, but has never been approved by the FDA. Depending on the practitioner, the chemicals vary although phosphatidylcholine is the most common drug used and, again, is not FDA approved for injection under the skin.

Leading mesotherapy advocate Lionel Bissoon, learned the specialty in France five years ago and is now promoting the procedure here. He says the procedure can be used as a delivery system for more than fighting fat. "We can treat migraine headaches, back pain, constipation, sports-medicine injuries, arthritis." This type of blanket endorsement, of course leads to doubt about the overall effectiveness of the treatment.

Our advice to patients considering this treatment is to be very cautious in making a decision to undergo this treatment. Since repeated treatments are required, the cost can be significant. Mesotherapy is not cheap: Each session costs an average of $500, and 10 to 15 sessions are recommended, for a total price tag similar to liposuction.

Breastfeeding does not cause ptotic breasts, study suggests

According to a brief article appearing Cosmetic Surgery Times E-News, researchers at the University of Kentucky studied a group of 132 women who sought breast lift or augmentation. About 60% had breastfed. The doctors concluded, based on their analysis, that the women who had breastfed developed no more sagginess than those that hadn’t. This is in sharp contrast to the general feeling among cosmetic surgeons that breast sagging is often related to breast feeding.

The researchers did find that pregnancy definitely did contribute to breast sagging, as did smoking, which breaks down the elastic tissue of the skin.

While of interest, it is important to note that the small number of patients studied may be suggestive but should not be taken for absolute fact.

That’s it for this addition. As always we appreciate your comments and suggestions.

Sincerely,

Howard A. Tobin, M.D., F. A. C. S.
www.newlook.org

For general information: askdena@newlook.org or n41gt@newlook.org