William H. Gorman, M.D., F.A.C.S.

Abdominoplasty – “Tummy-tuck” Questions and Answers

2011-03-31T16:41:00.000-05:00

Patients frequently ask what they can do to tighten or restore the shape of their abdomen. This may be following the birth of children or after significant weight loss. Whatever the cause of the problem, it seems that exercise and diet will often not be enough to reverse the damage. An abdominoplasty may be the answer. It is necessary to first identify the extent of the problem and whether it involves skin only, skin and fat, or deeper structures such as the muscles and fascia of the abdominal wall. An operation can then be planned to correct the problems.

Q. What is an abdominoplasty? Is it the same as a tummy tuck?

A. An abdominoplasty is primarily an aesthetic (cosmetic) procedure used to correct deformities of the skin, fat, muscles and fascia of the abdomen. The procedure is sometimes called a tummy tuck.

Q. How do I know whether I need a tummy tuck or just liposuction?

A. Sometimes the patient realizes only that their abdomen protrudes, fat and skin bulge and hang over their belt, or they have difficulty holding their stomach in. Your plastic surgeon will be able to quickly determine whether the problem is primarily fat or involves skin and deeper structures. If the problem is mainly fat and the skin is not significantly loose, then liposuction may be all that is needed. A physical exam will give the answer.

Q. Where is the incision for a tummy tuck? How big will it be?

A. The typical abdominoplasty incision is a low transverse (horizontal) incision, individually designed so that the necessary operation can be performed and the resulting scar can be hidden under minimal clothing. The length of the incision depends on the amount of skin that must be excised.

Q. Will I have a belly button after having a tummy tuck?

A. Yes, the belly button or umbilicus will remain although it will be brought out through a new “button hole” in the now tightened abdominal skin.

Q. How long will I need to take off from work? When can I return to normal activity? Will I have any limitations after surgery?

A. Most patients take 10-14 days off from work. Sedentary work can be done before then, depending on the patient. Limitations on straining, range of motion and running usually extend to about 2 months. Lighter exercise such as walking and light weights can resume after 2 weeks.

Q. Is the recovery painful?

A. Post operative pain varies from patient to patient, but the new “Pain Pump” technology and good pain medication help.

Q. Will I still need to diet and exercise after having a tummy tuck?

A. Absolutely! You will want to continue to improve your body and your health through exercise and diet.

Q. Is the surgery performed in a hospital or in the office?

A. In my practice, we do this procedure in a hospital with general anesthesia given by board certified anesthesiologists.

Q. How long does the operation last? How long will I be in recovery? Do I have to stay in the hospital over night?

A. Depending on the extent of the abdominoplasty, the procedure will take approximately 3 hours. You will be in the recovery room about one hour and we usually include one overnight stay.

Q. Do I have to wear any special garments after surgery?

A. In addition to surgical dressings, you will be placed in an abdominal binder which is primarily used for postoperative comfort and support.

Q. What are the risks involved with this surgery?

A. All surgical procedures carry some inherent risks, and abdominoplasty is no exception. Complications such as infection, bleeding and wound healing problems are very rare. Potential risks and complications will be discussed with you in detail prior to surgery so that proper consent can be obtained.

Q. What does a tummy tuck cost?

A. The cost for an abdominoplasty will depend on the extent of the surgery, length of the procedure and other considerations. As a general ball park figure, the cost including surgeon, operating room and anesthesia will be around $8,000.

Breast Implants May Be Linked to Rare Cancer, FDA Says

2011-03-10T13:29:00.000-06:00

Robert Lowes
Freelance writer, St. Louis, Missouri

January 26, 2011 — Patients with either saline- or silicone gel–filled breast implants may have a very small but significant risk for a rare cancer called anaplastic large-cell lymphoma (ALCL) adjacent to the implant, the US Food and Drug Administration (FDA) announced today.

While the agency continues to investigate the possible association between ALCL and breast implants, it is advising clinicians to consider the possibility of the cancer in patients with breast implants with late onset of fluid build-up called persistent peri-implant seroma. Clinicians also should report any confirmed cases of ALCL in women with breast implants to the FDA.

The agency is advising women with breast implants not to change their routine medical care and follow-up. Because the risk for ALCL appears to be very small, the agency believes the weight of evidence "supports a reasonable assurance that FDA-approved breast implants are safe and effective when used as labeled."

A rare cancer of the immune system that can occur anywhere in the body, ALCL is diagnosed in 1 of every 500,000 women per year in the United States. ALCL in the breast is rarer still, diagnosed annually in roughly 3 of every 100 million women without implants. In women with breast implants, it is usually inside the fibrous scar tissue — called a capsule — surrounding the implant. It is not a cancer of the breast per se.

Treatment options for ALCL are chemotherapy, radiation, and surgery, said William Maisel, MD, MPH, chief scientist and deputy director for science in the FDA's Center for Devices and Radiological Health, at a press conference today. The evidence suggests that the kind of ALCL found in conjunction with breast implants is less aggressive and is sometimes
treatable by simply removing the implant, the capsule, and collected fluid, according to Dr. Maisel.

An FDA review of scientific literature published from January 1997 through May 2010 uncovered 34 unique cases of ALCL in women with breast implants throughout the world. The agency is aware of 60 cases in all, some of them identified through other channels. The FDA does not know how many of the 60 may be duplicates of cases found in the literature. An estimated 5 million to 10 million women worldwide have received breast implants, according to the FDA.

Of the 31 published cases of ALCL, 24 involved silicone implants, and 7 saline implants. The median time from implant to ALCL diagnosis was 8 years. For most of the women, the cancer was diagnosed when they sought treatment for implant-related symptoms, such as pain, lumps, swelling, or asymmetry, after their surgical sites had healed. These symptoms result from persistent peri-implant seroma, hardening of the breast area around the implant, or masses surrounding the implant.

Plastic Surgeons and FDA Will Develop Patient Registry

The vast majority of data suggesting a link between ALCL and breast implants emerged only after the FDA approved silicone gel breast implants made by Allergan and Mentor in 2006, said Dr. Maisel. From 1992 to 2006, such silicone gel implants were available only on an investigational basis.

Dr. Maisel noted that silicone from ruptured and even intact implants has been found in nearby breast tissue. According to one theory about the origins of ALCL, this silicone chronically stimulates immune system T cells and induces lymphoma.

"Please understand that is speculative, and a hypothesis," said Dr. Maisel.

To get to firmer scientific ground, the FDA will collaborate with the American Society of Plastic Surgeons and other groups to develop a registry to collect more information that would better characterize ALCL in women with breast implants. The agency also is asking implant manufacturers to report ALCL cases. And for the sake of patient and clinician education, the FDA will work with these manufacturers to update product labeling materials.

More information about today's announcement is available on the FDA Web site. The FDA's preliminary findings and analyses are available here.

To report adverse events related to breast implants, contact MedWatch, the FDA's safety information and adverse event reporting program, by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online athttp://www.fda.gov/medwatch, or by mail to MedWatch, FDA, 5600 Fishers Lane, Rockville, Maryland 20852-9787.
Medscape Medical News © 2011 WebMD, LLC
Send comments and news tips to news@medscape.net.

Breast Augmentation Questions and Answers

2011-02-03T14:05:00.002-06:00

Q. Who is a good candidate for breast augmentation?

A. One group of women who often ask for breast augmentations are young women who never developed adequate breast size. They want to have larger breasts to be proportional with the rest of their body, to look good in their clothing and to enhance their sexuality. Another group of women who frequently ask for breast augmentations are women who have had children and have subsequently lost volume in her breasts.

Q. What is the breast augmentation consultation like?

A. In my practice, the consultation will take about one hour. After a review of the past medical history is done and an examination is performed, the procedure of breast augmentation will be discussed in great detail. This discussion will consider all aspects of the procedure including potential risks and complications as well as total costs. Photographs are often taken in this initial consultation.

Q. What incisions are used?

A. The most common incision is a small incision line in the lower crease of the breast or inframammary fold. This incision offers direct accessibility, avoids incisions in the breast tissue itself and can be used over again if needed. And incision can be made in the armpit or axilla which has the advantage of leaving no scar on the breast itself. However, it can typically be used only once. The third possible incision is around the nipple areola. This leaves a good scar and can be used again, but can possibly lead to problems in nursing. All of these approaches tend to leave excellent scars which fade to thin lines within one year.

Q. Should the implants be placed above or below the muscle?

A. For the best results, the breast implant should be covered with enough tissue so that implant ripples cannot be felt or visualized. Sometimes this requires placement of the implant underneath the pectoralis major muscle, but not always. This determination is typically based on the examination of the patient.

Q. What are the different types of implants available?

A. All breast implants have silicone shells. The shell may be smooth or textured and the implant may be filled with saline or silicone gel. All of silicone gel implants are now cohesive, meaning that they are a true gel rather than liquid. One implant known as the “Gummy Bear” has a rather thick gel and is only available to patients who fit the protocol of a research study.

Q. Can I breast feed after having a breast augmentation?

A. Breast implants themselves do not interfere with nursing. This is especially true when the incisions are either in the fold or armpit. Incisions through the nipple areola can sometimes damage to ductal tissue.

Q. Are the new silicone gel implants safe?

A. Yes. The new silicone gel implants were approved by the FDA three years ago after 15 years of research. I have personally been involved in this research since 1994 and am currently involved in the research on the “Gummy Bear” implant. This research overwhelmingly proves the safety of the implants, but as with all medically implanted material there can be certain risks and complications. These will be discussed thoroughly in the consultation.

Q. What about the recent news about the link between breast implants and a rare form of cancer?

A. The FDA recently announced a possible association between breast implants, both saline and silicone, and anaplastic large cell lymphoma, also known as ALCL. There have been 60 cases of this disease discovered worldwide among an estimated 10 million women with breast implants. This is much rarer than other forms of breast cancer. The majority of these cancers have been found in capsules surrounding the implants. Most of these patients had sought medical care for pain, lumps or swelling of their breast. In 27 years of performing breast augmentation, I have never seen this condition although I will certainly be on the lookout. The FDA says there is no need for women with implants to change their routine medical care or follow-up exams.

Q. How do you determine which size implant to use?

A. First, I listen to the patient; because I believe she has a pretty good idea about what she wants to look like once she has her implants. The patient will look at pictures of models or former patients in order to show me the final result she is after. In the operating room, sizer implants are used and adjusted until the proper and exact size determination is made. Only then are the new implants opened and inserted.

Q. How much time does the surgery take? Is an overnight stay necessary?

A. The procedure usually takes about an hour of actual surgery. It is typically performed as an outpatient procedure.

Q. Where do you do this procedure and what kind of anesthesia is used?

A. Most commonly I perform breast augmentation at the Austin Surgical Hospital which is a fully licensed and accredited facility. Anesthesia is given by a board certified Anesthesiologist.

Q. What kind of anesthesia is used and is the anesthesia safe?

A. Typically general anesthesia is used and with a board certified anesthesiologist administering the anesthesia, it is extremely safe.

Q. What is the recovery like and are there limitations?

A. Most patients are able to return to work within 3 to 5 days after the surgery. In order to assure the best results, some limitations will be placed on activity for several weeks postoperatively. However, walking, elliptical trainer, stationary bicycle and light weights are allowed early on.

Q. What medications will I be required to take?

A. You will be given a prescription for an antibiotic, pain medication and other medications as needed.

Q. What risks and complications are associated with breast augmentation?

A. All surgical procedures carry some expected symptoms such as swelling, bruising, discomfort and pain, temporary numbness, itching and redness of scars. Common risks associated with any operation include possible bleeding or hematoma, inflammation and infection, unsightly scars, delayed healing and injury to deeper structures. The incidence of these risks is rare. Even more rare would be medical complications such as pulmonary embolism, allergic reactions to medications cardiac arrhythmias and hyperthermia. Complications related to breast implants include capsular contracture, wrinkling or rippling, asymmetry, deflation and reported autoimmune disorders.

Q. What is capsular contracture? Is there anything I can do to prevent it?

A. Breast implants are recognized by the body as foreign material. The normal response of the body to foreign material is to place a layer of scar around it. The scar is typically a thin membrane but may sometimes thicken and contract around the implant. This results in a “shrink wrap” effect and makes the breast feel firm. Usually, 95% of the time, capsular contracture can be prevented. The other 5% may require surgical treatment.

Q. What does it cost to have a breast augmentation?

A. The fee for this procedure has several variables such as type of implant used, anesthesia options, surgical facility. Typically the total cost will be somewhere between $5000 and $6500.

Smartlipo: What makes it smart?

2011-01-17T13:08:00.005-06:00

Q: What is liposuction and how does it work?

A: Everyone has a fixed number of fat cells present in their body. These fat cells get smaller or larger as we lose or gain weight, but the number of fat cells remains the same. Liposuction is a way to remove fat cells in a specific area, especially in areas that may be resistant to diet and exercise. Liposuction is more about reducing inches than pounds – since fat doesn’t weigh that much.

Q: If I have liposuction, do I still have to diet and exercise?

A: In a word – YES. Your results will be enhanced when there is collaboration between you and the surgeon. He will reduce the number of your fat cells , but your remaining fat cells can enlarge if you don’t work at maintenance or even weight loss. Weight resistance exercises are also important to improve your lean body mass.

Q: How is Smartlipo^® different from traditional liposuction?

A: Traditional liposuction is performed in the operating room under general anesthesia. After a sterile liquid solution in injected to reduce bleeding, a thin hollow tube called a cannula is inserted through small incisions where it is moved back and forth to loosen excess fat. The dislodged fat is then suctioned out using a surgical vacuum. Now with Smartlipo^®, the procedure is performed in the office under local anesthesia. The cannula, which is much smaller than the traditional liposuction cannula, delivers energy through a laser directly to the fat cells, liquefying them. The fat is then gently suctioned out. After the fat is suctioned out, new collagen is produced, resulting in tightening of the tissue. The incisions are so small, no sutures are required.

Q: Is it painful? What is the recovery time like?

A: Because Smartlipo^® is more gentle than traditional liposuction, the incisions are smaller and it is done under local anesthesia, the recovery time is less and the pain is minimal. Patients can return to most normal activities within a day or two after surgery with some limitations.

Q: How long does the procedure take?

A: Depending on the number and size of the areas you choose to have treated, most procedures take between 30 minutes and 2 1/2 hours.

Q: Are the results visible right away?

A: Some immediate improvement will be seen after surgery, but the majority of the improvement will come over the first three months as swelling resolves and collagen begins the tightening process.

Q: On which areas of the body can Smartlipo^®be performed ?

A: Smartlipo^®can be used on the neck, abdomen, flanks (hips), back and thighs.

Q: Are there risks involved?

A: Though Smartlipo^®is relatively quick and simple, as with all surgeries there are potential risks associated with it. These are rare and will be discussed with you prior to the procedure.

Q: Does Smartlipo^® have to be performed by a plastic surgeon?

A: Success in any procedure comes from experience. This is true with liposuction as well. It is a surgical procedure and a board certified plastic surgeon will likely have the most experience in liposuction and body contouring procedures. When choosing a surgeon, make sure they are board certified and that they have extensive experience in body contouring procedures.

Q: Does Smartlipo^®replace the need for other surgical procedures?

A: Smartlipo^® is a wonderful option for fat reduction and body contouring. It also induces some skin tightening. However, it does not produce the same level of skin tightening a facelift or tummy-tuck would. Feedback from our patients has shown a great level of satisfaction with this procedure.

Please contact our office for a free consultation to discuss Smartlipo^®and how it can help you.